Titolo del documento

Commercial versus home-made spacers in delivering bronchodilator therapy for acute therapy in children.

Autori e Nazionalità

Rodriguez C, Sossa M, Lozano J

Fonte bibliografica

Cochrane Database Syst Rev 2008; apr 16:(2):CD005536.

Lingua

Inglese

Abstract

BACKGROUND: Strong evidence supports the use of metered-dose inhalers combined with a spacer for delivering rapid-acting inhaled beta-2 agonists in the treatment of acute exacerbations of asthma in children. The high cost and lack of availability of commercially produced spacers however, have limited their use in developing countries. OBJECTIVES: The aim of this review was to compare the response to inhaled beta-2 agonists delivered through metered-dose inhaler using home-made spacers, to the use of commercially produced spacers, in children with acute exacerbations of wheezing or asthma. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) The Cochrane Library Issue 3, 2007,(up to August 2007) MEDLINE , EMBASE, CINHAL, LILACS and reference lists of included studies. We contacted authors and known experts in the field, and approached pharmaceutical companies that manufacture inhalation spacers to identify additional published or unpublished data. No language restrictions were applied. SELECTION CRITERIA: Trials comparing treatment with rapid acting beta 2-agonists delivered though MDI attached to home-made spacers, with the same bronchodilator therapy delivered with MDI and commercially produced spacers, in children under 18 years with acute exacerbations of wheezing or asthma. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted the data and assessed trial quality. Missing data were obtained from the authors or estimated from information available in published reports. MAIN RESULTS: Six trials with 658 participants met the inclusion criteria . At the time of this report, five trials were published in full text, and one study was available in abstract form only. No significant differences were demonstrated between the two delivery methods in terms of need for hospital admission (RR 1.00, 95% CI 0.63 to 1.59), change in oxygen saturation (SMD -0.03, 95% CI -0.39 to 0.33), PEFR (SMD 0.04, 95% CI -0.72 to 0.80), clinical score (WMD 0.00, 95% CI -0.37 to 0.37), in terms of need for additional treatment (RR 1.18, 95% CI 0.84 to 1.65), or regarding change in heart rate per minute (SMD 0.09, 95% CI -0.24 to 0.42). AUTHORS' CONCLUSIONS: Overall, this review supports did not identify a difference between these two methods for delivering bronchodilator therapy to children with acute asthma or lower airways obstruction attacks. Care should be taken in the interpretation and applicability of our results because of the small number of RCTs along with few events available meeting the criteria for inclusion in the review, absence of the primary outcome of interest and other clinically important outcomes in the majority of included studies. The possible need for a face-mask in younger children using home-made spacers should also be considered in practice.

PMID

PMID: 18425921 [PubMed - in process]

Tipo di studio

Revisione Sistematica con metaanalisi

Livello di efficacia

1+

Commento

6 studi con 658 bambini dimostrano che non esistono differenze nel somministrare i broncodilatatori tramite distanziatori commerciali vs quelli fatti in casa per quanto riguarda i ricoveri in ospedale, le modifiche della saturazione di ossigeno, del PEFR, dello score clinico, , della necessità di ulteriore trattamento, della modifiche della frequenza cardiaca.

Titolo del documento

A longitudinal assessment of the effect of inhaled fluticasone propionate therapy on adrenal function and growth in young children with asthma

Autori e Nazionalità

Iles R, Williams RW, Deeb A, Ross-Russell R, Acerini CL. Gran Bretagna.

Fonte bibliografica

2008 febbr 19 (Epub ehead of print)

Lingua

Inglese

Abstract

OBJECTIVE: Fluticasone proprionate (FP) is increasingly used to treat very young children with asthma. Its safety in terms of effects on the hypothalamic pituitary axis (HPA) and growth in this age group is uncertain. PATIENTS AND METHODS:: Eleven children (median (range) age 10 (5.6-24.3) months) presenting with recurrent wheeze and family history of asthma were studied prospectively for a period of 18 months. Children received daily-inhaled FP 250 microg via a spacer device. No other corticosteroid therapy was administered prior to or during the study. A Short Standard Synacthen Test (SST) (125 microg) was performed pretreatment, and after 6 and 18 months. Weight (Wt), height (Ht), and body mass index (BMI) were measured at 3-6 monthly intervals. RESULTS:: Fasting early morning and peak cortisol levels remained within the normal reference range with therapy. There were no changes in Ht SDS, whereas both Wt SDS (baseline 0.05 (-2.17 to 0.52) vs. +18 months 0.68 (-0.5 to 1.36) P < 0.02) and BMI SDS (-0.22 (-1.73 to 0.75) vs. 0.86 (0.03 to 1.99) P < 0.005) increased after 18 months of treatment. CONCLUSION:: Daily treatment with inhaled FP 250 microg in young children with asthma appears to have no adverse effects on the HPA or on linear growth, however, treatment is associated with increases in body Wt and BMI in young children. Pediatr Pulmonol. (c) 2008 Wiley-Liss, Inc.

 

PMID

PMID: 18286548

Tipo di studio

Osservazionale

Livello di efficacia

2+

Commento

11 bambini di età media 10 mesi con broncospasmo ricorrente, che hanno assunto FP 200 ugr/die X 18 mesi non hanno avuto modifiche della funzionalità surrenalica, come confermato da un test di stimolo breve con  Synacten, nè riduzioni della velocità di crescita. E' stato segnalato un significativo aumento del BMI SDS. Non era previsto alcun gruppo di controllo.

Titolo del documento

Assessment of inhalation technique in children in general practice: increased risk of incorrect performance with new device

Autori e Nazionalità

ten Have WH, Van De Berg NJ, Bindels PJE, Van Aalderen WMC, Van der Palen J. Olanda

Fonte bibliografica

 Asthma 2008;45:67-71

Lingua

Inglese

Abstract

In a general practice based population 76% of 530 children inhaling asthma medication inhaled correctly. However, important differences among inhalers were found. Children with a pressurized metered-dose inhaler without a spacer device performed worst, with only 22% inhaling without essential errors. At a second evaluation of the inhaler technique, one year after the first assessment, performances with a new device were more often incorrect versus the unchanged devices (21.1% and 10.8%, respectively; p = 0.01). Providing children with a new device should be carefully controlled over time especially because these children are error prone.

 

PMID

PMID: 18259998 [PubMed - in process]

Tipo di studio

Osservazionale

Livello di evidenza

2+

Commento

Ancora uno studio che dimostra come gli spray non devono essere usati senza distanziatore e come sia necessario insegnare accuratamente la corretta tecnica inalatoria

testo

Titolo del documento

Inadequate skill of healthcare professionals in using asthma inhalation devices 

Autori e Nazionalità

Self TH, Arnold LB, Czosnowsky LM, Swanson JM, Swanson H. USA

Fonte bibliografica

J Asthma 2007;44:593-598 

Lingua

Inglese

Abstract

Inadequate skill in the use of asthma inhalation devices by healthcare professionals has been well documented over the past 25 years. We performed a PubMed search of the English literature for studies regarding skill by physicians, medical students, pharmacists, nurses, and respiratory therapists in using asthma inhalation devices. This review summarizes 20 studies that were identified. Results of these studies consistently showed lack of skill in using metered-dose inhalers, spacers, and dry powder inhalers by a majority of healthcare professionals. National and international guidelines for asthma management include detailed patient education as an essential component of care, yet a large percentage of healthcare professionals are not competent in using inhalation devices. Practical solutions to this problem are needed to enhance

PMID

PMID: 17943567 [PubMed - indexed for MEDLINE]

Tipo di studio

Revisione

Livello di evidenza

2+

Commento

Questa Revisione ha preso in esame i 20 studi che analizzano le competenze di medici, infermieri, farmacisti e terapisti respiratori riguardo i distanziatori e gli erogatori di polvere secca. Queste figure professionali hanno scarsa conoscenza della tecnica inalatoria, in questo articolo vengono anche proposti dei suggerimenti per migliorare questa situazione. 

Titolo del documento

Retention by children of device technique for inhaled asthma drugs between visits

Autori e Nazionalità

Munzenberger PJ, Thomas R, Bahrainwala A. USA 

Fonte bibliografica

J Asthma 2007;44(9):269-273 

Lingua

Inglese

Abstract

This study determined retention by children of drug delivery device technique between visits. Patients had asthma requiring the daily use of at least one medication delivery device. Seventy-two patients completed the study; 24 used only the metered dose inhaler (MDI) (group 1), while 48 used the MDI and 1 other device (group 2). Patients or caregivers were initially instructed on and demonstrated the correct use of their medication delivery device(s). At their next visit, they demonstrated their technique for each device. At follow-up, 36% correctly performed all components of the MDI. Group 1 (50%) was higher than group 2 (29%). The percent of correct MDI components for group 1 (84) was also higher than group 2 (78) but not significantly. For both groups and devices, breathing out before inhalation and breath holding was problematic. This study reinforces the need to demonstrate and observe the correct use of inhalation devices at each clinic visit.

 

PMID

PMID: 17994409 [PubMed - indexed for MEDLINE]

Tipo di studio

Osservazionale

Livello di evidenza

2+

Commento

Questo studio rinforza il messaggio che si deve controllare la tecnica inalatoria dei pazienti durante ogni visita

Titolo del documento

Incorrect application technique of metered dose inhalers by internal medicine residents: impact of exposure to a practical situation

Autori e Nazionalità

Stelmach R, Robles-Ribeiro PG, Ribeiro M, Oliveira JC, Scalabrini A, Cukier A. Brasile 

Fonte bibliografica

J Asthma 2007;44:765-768

Lingua

Inglese

Abstract

We evaluated residents regarding maintenance treatment of asthma and the technique for using metered dose inhalers. Methods. Residents were asked to prescribe a treatment for a patient with poorly controlled persistent asthma and to demonstrate the use of metered dose inhaler (MDI) medication. Results. 76% of 239 residents correctly identified the medication indicated for the case; only 30% of them adequately performed the inhalation technique (49% from HCFMUSP vs. 19% from other institutions; p < 0.001). Conclusions. The results demonstrate that, when seeing a typical patient with uncontrolled persistent asthma, most residents are able to correctly identify the drugs indicated for treatment but not adequately instruct the MDI technique use

PMID

PMID: 17994408 [PubMed - indexed for MEDLINE]

Tipo di studio

Osservazionale

Livello di evidenza

2+

Commento

Solo il 30% dei medici al loro II anno di training in Medicina Interna possiede un'adeguata tecnica inalatoria con gli spray (nessuno spacer era disponibile), mentre la maggior parte di loro identifica il tipo di farmaco corretto per il paziente asmatico: questo significa che anche se i medici specializzandi hanno buone basi teoriche poi non sanno trasferire nella pratica queste loro conoscenze.

Titolo del documento

Randomized trial of spacers in asthma

Autori e Nazionalità

Dahiya B, Mathew JL, Singh M. India 

Fonte bibliografica

Indian J Pediatr 2007;74(7):631-5.

Lingua

Inglese

Abstract

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 200 mg salbutamol through one of five spacers: A) 750 ml spacer with valve, B) 165 ml spacer with valve, C) 250 ml spacer without valve, D) 1000 ml indigenously made spacer without valve and E) 500 ml 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.

PMID

PMID: 17699970 [PubMed - in process]

Tipo di studio

Randomizzato

Livello di evidenza

1+

Commento

5 distanziatori di volume diverso (da 165 ml a 1000 ml con o senza valvole) sono ugualmente efficaci nel migliorare il FEV1 e il PEF.

Titolo del documento

Barriers to metered-dose inhaler/spacer use in Canadian Pediatric Emergency Departments: a National Survey

Autori e Nazionalità

Fonte bibliografica

Lingua

Abstract

PMID

Tipo di studio

Livello di evidenza

2+

Commento

Nonostante i medici e le infermiere che lavorano nei Pronto Soccorso pediatrici canadesi sia consapevole che utilizzare lo spray con il distanziatore sia altrettanto efficace dei nebulizzatori per somministrare i broncodilatatori nella terapia dell'attacco acuto d'asma, con alcuni vantaggi, la maggior parte continua a preferire i nebulizzatori. Tra i motivi principali di questa scelta: la preoccupazione dei costi e del maggior carico di lavoro, le problematiche relative alla sterilizzazione, le aspettative dei genitori. Queste le principali barriere per una maggior diffusione delle camere di espansione.

Titolo del documento

Valved holding chambesr for use with pressurised metered-dose inhalers: a review of causes of inconsistent medication delivery.

Autori e Nazionalità

Mitchell JP, Nagel MN. Canada

Fonte bibliografica

Primary Care Respir Journal 2007;16:Ahead of print

Lingua

Inglese

Abstract

BACKGROUND: Valved holding chambers (VHCs) are prescribed with pressurised metered dose inhalers (pMDIs) to improve medication delivery for the treatment of respiratory diseases because they reduce the need for the patient to co-ordinate inhaler actuation with the onset of inhalation. Although mechanically robust and clinically effective if properly designed and pre-conditioned, there are several causes of inconsistent medication delivery if this is not the case. These include: electrostatic charge; incorrect operation of inhalation and exhalation valves; and the fit of the facemask - where present - to the face. In addition, behavioral factors, such as not following patient instructions for use and maintenance, and imperfect breathing technique, amplify overall variability. Aids such as valve movement indicators that provide patient feedback are helpful in order to minimise these factors. METHODS: This article reviews recent literature concerning the causes of inconsistent drug delivery and the improvements that have been made by manufacturers to VHC devices, and assesses the clinical implications. The attributes of a well-designed VHC are summarised.

PMID

17625786 [PubMed - as supplied by publisher]

Tipo di studio

Revisione narrativa 

Livello di evidenza

4

Commento

I fattori che influenzano la quota di farmaco che spruzzata nel distanziatore arriva al paziente: il volume, le valvole, il disegno e le caratteristiche della mascherina, le cariche elettrostatiche

Titolo del documento

Metered dose inhaler add-on devices: is the inhaled mass of drug depenedent on the size of the infant ?

Autori e Nazionalità

Tupeinen M, Nikander K, Malmberb LP, Pelkonen A. Finlandia

Fonte bibliografica

J Aerosol Med 1999;12:171-176. 

Lingua

Inglese

Abstract

Limited cooperation and low tidal volumes in infants make aerosol therapy difficult. We measured the amount of drug delivered from two baby spacer devices especially developed for use in infants. Designed as a randomized crossover study, aerolized budesonide from a pressurized metered dose inhaler (pMDI) was collected in the inspiratory filter interposed between the face mask and the spacer in 13 infants aged from 2 to 19 months old. The study was performed in connection with pulmonary function testing with a plethysmograph, and the children were sedated with cloral hydrate. Two small-volume baby spacer devices were used: a Babyhaler spacer (GlaxoWellcome, Hertfordshire, UK) made of polycarbonate with a volume of 350 mL and a built-in dead space of 40 mL and a NebuChamber spacer (AstraZeneca, Lund, Sweden) made of stainless steel with a volume of 250 mL and no dead space. Budesonide delivery from the NebuChamber was significantly higher than from the Babyhaler: 38.2% (range, 28.3%-47.5%) of the nominal dose versus 12% (range, 3.3%-21.25%) of the nominal dose of 400 micrograms of budesonide (P = 0.002). The inhaled mass of budesonide from the Babyhaler correlated significantly with skin surface area (r = 0.68, P = 0.018), weight (r = 0.66, P = 0.019), height (r = 0.69; P = 0.017), tidal volume (r = 0.82; P = 0.004), and minute volume (r = 0.67; P = 0.019). No correlations were found between these variables and the inhaled mass of budesonide from the NebuChamber. The results indicate that the design of the NebuChamber spacer affords stable drug delivery in infants and that a large variability in the inhaled mass of drug may be found when infants are inhaling from different baby spacers.

PMID

10623333 [PubMed - indexed for MEDLINE]

Tipo di studio

Osservazionale

Livello di evidenza

2+ 

Commento

Il disegno è il materiale della Nebuchamber di metallo consente di ottenere una minor variabilità nella dose di farmaco inalata rispetto al Babyhaler, che  possiede anche un notevole spazio morto fra le valvole di 40 ml.

Titolo del documento

Holding chambers (spacers) versus nebulisers for beta-agonists treatament of acute asthma

Autori e Nazionalità

Cates CJ, Crilly JA, Rowe BH. Gran Bretagna

Fonte bibliografica

Cochrane Database Syst Rev 2006 apr 19;(2):CD000052

Lingua

Inglese

Abstract

BACKGROUND: In acute asthma inhaled beta2-agonists are often administered to relieve bronchospasm by wet nebulisation, but some have argued that metered-dose inhalers with a holding chamber (spacer) can be equally effective. Nebulisers require a power source and need regular maintenance, and are more expensive in the community setting. OBJECTIVES: To assess the effects of holding chambers (spacers) compared to nebulisers for the delivery of beta2-agonists for acute asthma. SEARCH STRATEGY: We last searched the Cochrane Airways Group trials register in January 2006 and the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 4, 2005). SELECTION CRITERIA: Randomised trials in adults and children (from two years of age) with asthma, where spacer beta2-agonist delivery was compared with wet nebulisation. DATA COLLECTION AND ANALYSIS: Two reviewers independently applied study inclusion criteria (one reviewer for the first version of the review), extracted the data and assessed trial quality. Missing data were obtained from the authors or estimated. Results are reported with 95% confidence intervals (CI). MAIN RESULTS: This review has been updated in January 2006 and four new trials have been added. 2066 children and 614 adults are now included in 25 trials from emergency room and community settings. In addition, six trials on in-patients with acute asthma (213 children and 28 adults) have been reviewed. Method of delivery of beta2-agonist did not appear to affect hospital admission rates. In adults, the relative risk of admission for spacer versus nebuliser was 0.97 (95% CI 0.63 to 1.49). The relative risk for children was 0.65 (95% CI: 0.4 to 1.06). In children, length of stay in the emergency department was significantly shorter when the spacer was used, with a mean difference of -0.47 hours (95% CI: -0.58 to -0.37). Length of stay in the emergency department for adults was similar for the two delivery methods. Peak flow and forced expiratory volume were also similar for the two delivery methods. Pulse rate was lower for spacer in children, mean difference -7.6% baseline (95% CI: -9.9 to -5.3% baseline). AUTHORS' CONCLUSIONS: Metered-dose inhalers with spacer produced outcomes that were at least equivalent to nebuliser delivery. Spacers may have some advantages compared to nebulisers for children with acute asthma.

PMID

16625527 [PubMed - indexed for MEDLINE]

Tipo di studio

Revisione Sistematica con Meta-analisi

Livello di evidenza

1+

Commento

Per approfondire l'argomento si vedano i numeri di giugno, agosto e ottobre 2004 della RIAP

Titolo del documento

testo

Autori e Nazionalità

testo

Fonte bibliografica

testo

Lingua

testo

Abstract

testo

PMID

testo

Tipo di studio

testo

Livello di efficacia

testo

Disponibili per il download

testo

Titolo del documento

Spacer inhalation technique and deposition of extrafine aerosol in asthmatic children

Autori e Nazionalità

Roller CM, Zhang G, Troedson RG, Leach CL, Le Souef PN, Devadason SG. USA

Fonte bibliografica

Eur Respir J 2007;29:299-306

Lingua

Inglese

Abstract

The aim of the present study was to measure airway, oropharyngeal and gastrointestinal deposition of (99m)Tc-labelled hydrofluoroalkane-beclomethasone dipropionate after inhalation via a pressurised metered-dose inhaler and spacer (Aerochamber Plus) in asthmatic children. A group of 24 children (aged 5-17 yrs) with mild asthma inhaled the labelled drug. A total of 12 children took five tidal breaths after each actuation (tidal group). The other 12 children used a slow maximal inhalation followed by a 5 - 10-s breath-hold (breath-hold group). Simultaneous anterior and posterior planar gamma-scintigraphic scans (120-s acquisition) were recorded. For the tidal group, mean+/-sd lung deposition (% ex-actuator, attenuation corrected) was 35.4+/-18.3, 47.5+/-13.0 and 54.9+/-11.2 in patients aged 5-7 (n = 4), 8-10 (n = 4) and 11-17 yrs (n = 4), respectively. Oropharyngeal and gastrointestinal deposition was 24.0+/-10.5, 10.3+/-4.4 and 10.1+/-6.2. With the breath-hold technique, lung deposition was 58.1+/-6.7, 56.6+/-5.2 and 58.4+/-9.2. Oropharyngeal and gastrointestinal deposition was 12.9+/-3.2, 20.1+/-9.5 and 20.8+/-8.8. Inhalation of the extrafine formulation with the breath-hold technique showed significantly improved lung deposition compared with tidal breathing across all ages. Oropharyngeal and gastrointestinal deposition was markedly decreased, regardless of which inhalation technique was applied, compared with a previous paediatric study using the same formulation delivered via a breath-actuated metered-dose inhaler.

 

PMID

17005581 [PubMed - indexed for MEDLINE]

 

Tipo di studio

Osservazionale

Livello di evidenza

3

Commento

Misurata l’entità della deposizione polmonare e gastro-intestinale del beclometasone dipropionato HFA, che nella confezione spray  utilizza i nuovi propellenti Idrofluoroalcani: 25 bambini di età 5-17 anni con asma lieve, in fase stabile,  sono stati invitati ad assumere lo steroide inalatorio radiomarcato  con la tecnica del respiro corrente o con quella dell’inspirio profondo seguito da una pausa: coloro che utilizzavano la seconda modalità di inalazione presentavano una maggior deposizione polmonare del farmaco (58.1%  a 5-7 anni, 56.6% a 8-10 anni e 58.4 % a 11-7 anni) rispetto quelli che  eseguivano 5 atti respiratori a volume corrente (35,4% a 5-7 anni, 47,5% a 8-10 anni, 54,9% a 11-17 anni), con una differenza particolarmente evidente dunque nei pazienti più piccoli. Inoltre con l’inspirio profondo nei bambini di età 5-7 anni si aveva una minor deposizione oro-faringea e gastro-intestinale e una minor variabilità della dose che arrivava ai polmoni. Gli autori concludono il loro studio con l’invito ad utilizzare preferenzialmente la tecnica dell’inspirio profondo seguita da una pausa  nei bambini di età ≥ 5 anni.

Titolo del documento

La terapia inalatoria

Autori e Nazionalità

Battistini A. Italia

Fonte bibliografica

Medico e Bambino settembre 2007, in press

Lingua

Abstract

PMID

Tipo di studio

Livello di evidenza

Commento

Titolo del documento

Perceptual reasons for resistance to change in the Emergency department use of holding chambers for children with asthma

Autori e Nazionalità

Hurley KF, Sargeant J, Duffy J, Sketris I, Sinclair D, Ducharme J. Canada

Fonte bibliografica

Annals of Emergency Medicine 2007; 20:1-9.

Lingua

Abstract

PMID

Tipo di studio

Livello di evidenza

Commento

Titolo del documento

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

Autori e Nazionalità

Zar HJ, Streun S, Levin M, Weinberg EG, Swingler GH

Fonte bibliografica

Arch Dis Child 2007;92:142-146

Lingua

Inglese

Abstract

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

PMID

16905564 [PubMed - indexed for MEDLINE]

Tipo di studio

Randomizzato controllato

Livello di evidenza

1+

Commento

Titolo del documento

Lo spray con il distanziatore:istruzioni per l'uso

Autori e Nazionalità

Radzik D.Italia

Fonte bibliografica

Medico e Bambino settembre 2007, in press

Lingua

Italia

Abstract

There is clear evidence to support the use of a pressurized metered dose inhaler (pMDI)/spacer combination in the treatment of mild to moderate acute asthma rather than a nebulizer. With the first method there are additional benefits like fewer side effects and less time spent in the Emergency Department; furthermore spacers are cheaper and more portable. Nevertheless physicians, nurses, patients and their relatives seldom use this technique: reasons for this “nebulizer culture” are briefly analyzed and useful tips of best clinical practice on this topic are presented.

PMID

testo

Tipo di studio

Revisione

Livello di evidenza

Commento

Titolo del documento

Novel spacer device does not improve adherence in childhood asthma

Autori e Nazionalità

Burgess SW, Sly PD, Cooper DM, Devadason SG. Australia 

Fonte bibliografica

Pediatr Pulmonol 2007 Jun 22;(Epub ahead of print) 

Lingua

Inglese

Abstract

The Funhaler (FH) is a novel spacer device (holding chamber) that has been designed to improve adherence and aerosol delivery in young asthmatic children using a metered dose inhaler. A pilot study reported a 38% increase in parent-reported adherence over 2 weeks compared with the child's normal spacer. The aim of this study was to investigate whether the FH would be associated with superior adherence in the medium term (3 months) using an objective assessment. Forty-seven children aged 18 months to 7 years were randomised to a FH or control small volume spacer. Participants were reviewed monthly for 3 months. Adherence was measured using an electronic monitoring device (Smartinhaler). Disease control was based on symptom scores and exacerbation rates. Twenty-six children were randomised to the FH and 21 to the control spacer. Three children withdrew (FH = 2). Median adherence each month for the 3 months was 74%, 54%, and 46% for the FH and 70%, 73%, and 54% for the control spacer. The difference in adherence was not statistically significant (P = 0.47, 0.37, and 0.23, respectively). There was also no significant difference in exacerbation rates or symptom scores. Seven of the FHs broke during the study. The FH was preferred by 21/24 parents randomised to the FH compared with their child's normal spacer. Despite the FH being popular with children and parents its use was not associated with improved adherence or disease control

PMID

17588243 [PubMed - as supplied by publisher]

Tipo di studio

Osservazionale

Livello di evidenza

3

Commento

L'utilizzo del nuovo distanziatore Funhaler non si associa ad una migliore compliance rispetto all'utilizzo di uno spacer di controllo

Titolo del documento

Electrostatics and inhaled medications: influence on delivery via pressurized metered-dose inhalers and add-on devices

Autori e Nazionalità

Mitchell JP, Chem C, Coppolo DP, Nagel MW. Canada

Fonte bibliografica

Respiratory Care 2007;52:283-300

Lingua

Inglese

Abstract

The movement of inhaler-generated aerosols is significantly influenced by electrostatic charge on the particles and on adjacent surfaces. Particle charging arises in the aerosol formation process. Since almost all inhalers contain nonconducting components, these surfaces can also acquire charge during manufacture and use. Spacers and valved holding chambers used with pressurized metered-dose inhalers to treat obstructive lung diseases are particularly prone to this behavior, which increases variability in the amount of medication available for inhalation, and this is exacerbated by low ambient humidity. This may result in inconsistent medication delivery. Conditioning the device by washing it with a conductive surfactant (detergent) or using devices made of charge-dissipative/conducting materials can mitigate electrostatic charge. This review discusses sources of electrostatic charge, the processes that influence aerosol behavior, methods to mitigate electrostatic charge, and potential clinical implications.

PMID

PMID: 17328827 [PubMed - indexed for MEDLINE]

Tipo di studio

Revisione narrativa

Livello di evidenza

Commento

Questa revisione è un interessante carellata sulle cause delle cariche elettrostatiche, i processi che le determinano, i metodi per ridurle e le potenziali implicazioni cliniche.

Titolo del documento

Skills amongst parents of children with asthma: a pilot intereventional study in primary care setting.  

Autori e Nazionalità

Aziz NA, Norzila MZ, Hamid NG, Noorlaili MT 

Fonte bibliografica

Med J Malaysia 2006;61:534-9

Lingua

Inglese

Abstract

The increasing prevalence of childhood asthma has become a concern among health practitioners. Effective management emphasizes long-term management and inhaled therapy has become the mainstay home management for children. However, proper utilization of medication is pertinent in improving control. Proper asthma education is mandatory in improving skills and confidence amongst parents. To assess the skills of using the metered-dose inhaler (MDI) with a spacer among asthmatic children before and after educational intervention and to analyse any difficulties which may occur amongst the participants in executing the assessment steps. A cross-sectional clinic based study involving 85 parents and children with asthma. A standardized metered-dose inhaler-spacer checklist of eight steps of medication usage and five steps of cleaning the spacer were used as the assessment tools for pre and post intervention. The performance on using the inhaler-spacer and spacer cleaning knowledge pre and two months post intervention was evaluated. One point was given for each correct step and zero points for incorrect answers/steps. The mean score for skills of inhaler technique improved significantly after educational intervention (3.51 to 6.01, p < 0.0001) as did the mean score for parental knowledge of spacer cleaning technique (1.35 to 3.16, p 0.001). Analysis showed only a limited improvement even after an educational session in three steps of inhalation technique: step 5 (23.5%/69.4%), step 6 (28.2%/68.2%) and step 7 (25.9%/61.2%). Parents with asthmatic children had poor skills in utilizing their children's medication. A short-term educational intervention was able to improve overall knowledge and skill but certain skills need more emphasizing and training.

PMID

17623952 [PubMed - in process]

Tipo di studio

Osservazionale

Livello di evidenza

2+

Commento

Un programma educazionale basato sulla dimostrazione migliora la tecnica inalatoria dei bambini che usano il distanziatore, ma alcuni step vanno particolarmente ricontrollati , perchè sono più difficili da ricordare.

Titolo del documento

Assessment oh inhalation technique and detrminants of incorrect performance among children with asthma

Autori e Nazionalità

Walia M, Paul L, Satyavani A, Lodha R, Kalaivani M, Kabra SK. India

Fonte bibliografica

Pediatr Pulmonol 2006; 11:1082-7.

Lingua

Inglese

Abstract

The objective of our study was to evaluate the pressurized metered dose inhaler (pMDI) with holding chamber technique of asthmatic children attending out patient pediatric chest clinic and determine factors associated with incorrect technique. All patients had previously received instructions regarding inhalation technique. The inhalation technique was assessed on a five-point checklist, four of which were considered essential. Two hundred and thirteen children (mean +/- SD age, 7.3 +/- 3.8 years; 151 boys) completed the study. Children were using their inhaler for a median duration of 6 months (range 1-96 months). One hundred and eighty-eight patients (88.3%) performed all essential steps correctly. The commonest mistake among the essential steps was not shaking the inhaler (n = 21, 9.9%) followed by inability to make a tight seal around the mouthpiece of the holding chamber (n = 12, 5.6%). Correct technique was not affected by gender, asthma severity and socio-economic indices: education level of parents, percapita monthly income, rural or urban background. Our study indicates that a large majority of children from a developing country setting, irrespective of lower education and income levels can be successfully educated to appropriately use inhalation device. Inhalation performance is not affected by socio-economic background of the patients. Comprehensive inhalation instructions and monitoring at each visit are however critical to ensure reliable and consistent performance of correct technique among asthmatic children.

PMID

16989001 [PubMed - indexed for MEDLINE]

Tipo di studio

Osservazionale

Livello di evidenza

2+

Commento

In India la maggior parte dei bambini che sono stati educati nella tecnica dello spray con il distanziatore esegue correttamente l'inalazione. Gli errori più comuni: dimenticarsi di scuotere lo spray, non buona adesione del boccaglio in bocca

Titolo del documento

Concurrent use of metered-dose and dry powder inhalers by children with persistent asthma does not adversely affect spacer/inhaler technique

Autori e Nazionalità

Chan DS, Callahan CW, hatch-Pigott VB, Lawless A, Proffitt Hl, Manning NE, Schweikert  MP

Fonte bibliografica

Ann Pharmacother 2006;40:1743-6

Lingua

Inglese

Abstract

BACKGROUND: Studies conducted in adults have suggested that patients who use a metered-dose inhaler/holding chamber spacer (MDI/S) and dry powder inhaler (DPI) concurrently will have poorer MDI/S technique than that of patients who use MDI/S exclusively. To our knowledge, as of August 31, 2006, no studies have been performed in pediatric patients. OBJECTIVE: To compare MDI/S technique scores of children using only MDI/S with scores of those using both MDI/S and DPIs. METHODS: The MDI/S technique of children aged 6-17 years, with persistent asthma, recruited from a general pediatric practice population for an asthma intervention study project was scored using a standardized checklist. MDI/S scores of children who were being treated with maintenance and rescue medication delivered only by MDI/S were compared with those treated with both MDI/S (rescue) and DPI (maintenance). Scores lower than 70% were considered to be inadequate. RESULTS: A total of 117 patients (73 male, 44 female), aged 9.70 +/- 3.1 years (mean +/- SD), with persistent asthma, participated in the study. There were 83 children (54 male, 29 female, age 9.4 +/- 3.2 y) in the MDI/S only group and 34 (19 male, 15 female, age 10.3 +/- 2.9 y) in the MDI/S + DPI group. In the MDI/S + DPI group, Diskus was the DPI used for 32 patients, and Turbuhaler was used by 2 children. Sixteen patients had severe persistent asthma, 80 had moderate persistent asthma, and 21 had mild persistent asthma as classified by National Heart Lung and Blood Institute guidelines. No difference in sex and age demographics existed; however, there was a difference in the distribution of asthma severity between groups (ie, no patients with mild persistent asthma in the MDI/S + DPI group; p < or = 0.01). Mean score for the MDI/S only group was 86 +/- 17% and, for the MDI/S + DPI group, 90.1 +/- 12% (p = 0.15). More patients in the MDI/S group had inadequate scores (18%) compared with those in the MDI/S + DPI group (3%; p < 0.05). CONCLUSIONS: While DPI and MDI/S techniques are markedly different in several significant ways, concurrent use of these inhalers did not adversely affect MDI/S technique scores of pediatric patients with persistent asthma, compared with those using MDI/S alone. Patients in the MDI/S only group had an inadequate MDI/S score (<70%) more often than did patients in the MDI/S + DPI group.

PMID

16968822 [PubMed - indexed for MEDLINE]

Tipo di studio

Osservazionale

Livello di evidenza

3

Commento

testo

Titolo del documento

Force-dependent static dead space of face masks used with holding chambers.

Autori e Nazionalità

Shaha SA, Berlinski AB, Rubin BK. Usa

Fonte bibliografica

Respir Care 2006;51:140-144.

Lingua

Inglese

Abstract

BACKGROUND: Pressurized metered-dose inhalers with valved holding chambers and masks are commonly used for aerosol delivery in children. Drug delivery can decrease when the dead-space volume (DSV) of the valved holding chamber is increased, but there are no published data evaluating force-dependent DSV among different masks. METHODS: Seven masks were studied. Masks were sealed at the valved holding chamber end and filled with water to measure mask volume. To measure mask DSV we used a mannequin of 2-year-old-size face and we applied the mask with forces of 1.5, 3.5, and 7 pounds. Mask seal was determined by direct observation. Intra-brand analysis was done via analysis of variance. RESULTS: At 3.5 pounds of force, the DSV ranged from 29 mL to 100 mL, with 3 masks having DSV of < 50 mL. The remaining masks all had DSV > 60 mL. At 3.5 pounds of force, DSV percent of mask volume ranged from 33.7% (Aerochamber, p < 0.01 compared with other masks) to 100% (Pocket Chamber). DSV decreased with increasing force with most of the masks, and the slope of this line was inversely proportional to mask flexibility. Mask fit was 100% at 1.5 pounds of force only with the Aerochamber and Optichamber. Mask fit was poorest with the Vortex, Pocket Chamber, and BreatheRite masks. CONCLUSION: Rigid masks with large DSV might not be not suitable for use in children, especially if discomfort from the stiff mask makes its use less acceptable to the child.

PMID

16441958 [PubMed - indexed for MEDLINE]

Tipo di studio

Osservazionale

Livello di evidenza

2+

Commento

Lo spazio morto diminuisce con l'aumentare della forza con cui la maschera viene applicata al viso. Modelli rigidi come quelli usati sul Vortex sono pertanto poco adatti e spesso mal tollerati dal paziente

Titolo del documento

The need to improve inhalation technique in Europe: a report from the aerosol drug management improvement team

Autori e Nazionalità

Crompton GK, Barnes PJ, Broeders M, Corrigan C, Corbetta L, Dekhuijzen R, Dubus JC, Magnan A, Massone F, Sanchis J, Viejo JL, Voshaar T. Multicentrico

Fonte bibliografica

Lingua

Abstract

PMID

Tipo di studio

Livello di evidenza

Commento

Titolo del documento

Infant aerosol holding chambers facemasks: not alla are born equally ! Respir Care 2006;51:123-125.

Autori e Nazionalità

Amirav I. Israele 

Fonte bibliografica

Respir Care 2006;51:123-125

Lingua

Inglese

Abstract

testo

PMID

16441955 [PubMed - indexed for MEDLINE]

Tipo di studio

Editoriale ad un articolo inserito nella stessa rivista 

Livello di evidenza

4

Commento

Non tutte le maschere sono uguali: è importante saperlo, perchè quelle rigide devono essere applicate in modo molto aderente al viso e ciò comporta sconforto per il paziente: questo perchè con le maschere rigide lo spazio morto si riduce meno che con quelle morbide, man mano che si aumenta la loro pressione sul viso del paziente

Titolo del documento

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

Autori e Nazionalità

Cates CJ, Crilli JA, Rowe BH. Gran Bretagna

Fonte bibliografica

Cochrane Database Syst Rev 2006 apr 19;(2):CD000052 

Lingua

Inglese

Abstract

BACKGROUND: In acute asthma inhaled beta2-agonists are often administered to relieve bronchospasm by wet nebulisation, but some have argued that metered-dose inhalers with a holding chamber (spacer) can be equally effective. Nebulisers require a power source and need regular maintenance, and are more expensive in the community setting. OBJECTIVES: To assess the effects of holding chambers (spacers) compared to nebulisers for the delivery of beta2-agonists for acute asthma. SEARCH STRATEGY: We last searched the Cochrane Airways Group trials register in January 2006 and the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 4, 2005). SELECTION CRITERIA: Randomised trials in adults and children (from two years of age) with asthma, where spacer beta2-agonist delivery was compared with wet nebulisation. DATA COLLECTION AND ANALYSIS: Two reviewers independently applied study inclusion criteria (one reviewer for the first version of the review), extracted the data and assessed trial quality. Missing data were obtained from the authors or estimated. Results are reported with 95% confidence intervals (CI). MAIN RESULTS: This review has been updated in January 2006 and four new trials have been added. 2066 children and 614 adults are now included in 25 trials from emergency room and community settings. In addition, six trials on in-patients with acute asthma (213 children and 28 adults) have been reviewed. Method of delivery of beta2-agonist did not appear to affect hospital admission rates. In adults, the relative risk of admission for spacer versus nebuliser was 0.97 (95% CI 0.63 to 1.49). The relative risk for children was 0.65 (95% CI: 0.4 to 1.06). In children, length of stay in the emergency department was significantly shorter when the spacer was used, with a mean difference of -0.47 hours (95% CI: -0.58 to -0.37). Length of stay in the emergency department for adults was similar for the two delivery methods. Peak flow and forced expiratory volume were also similar for the two delivery methods. Pulse rate was lower for spacer in children, mean difference -7.6% baseline (95% CI: -9.9 to -5.3% baseline). AUTHORS' CONCLUSIONS: Metered-dose inhalers with spacer produced outcomes that were at least equivalent to nebuliser delivery. Spacers may have some advantages compared to nebulisers for children with acute asthma.

 

PMID

16625527 [PubMed - indexed for MEDLINE]

Tipo di studio

Revisione Sistematica con Meta-analisi

Livello di evidenza

1++

Commento

Per approfondire l'argomento si vedano i numeri della RIAP di  agosto, ottobre e maggio 2004

Titolo del documento

In vitro evaluation of the novel spacer device Watchhaler and modeling of probable deposition in children.

Autori e Nazionalità

Scheuch G, Kolb T, Sommerer K, Roeder S. Germania

Fonte bibliografica

Respir Drug Deliv 2006;10:1-3 

Lingua

Inglese

Abstract

In vitro il nuovo spacer Watchhaler dotato di incentivatore dimostra di poter raggiungere un'alta deposizione polmonare ed output del farmaco inalato.

PMID

Non presente in PubMed 

Tipo di studio

in vitro

Livello di evidenza

Commento

Sono necessari studi in vivo sul paziente di conferma

Titolo del documento

Aerosol therapy by pressured metered-dose inhaler-spacer in young children: to do or not to do ?

Autori e Nazionalità

Esposito-Festen J, Ijsselstijin H, Hop W, van Vliet F, de Jongste J, Tiddens H.  Olanda

Fonte bibliografica

Chest 2006;130:487-92

Lingua

Inglese

Abstract

One third of young children are distressed during inhalation therapy. It has been suggested that administration during sleep could be a good alternative for these children. A laboratory study in our department using an infant upper airway model showed significantly higher lung doses from a pressured metered-dose inhaler (pMDI)-spacer for sleep-breathing patterns compared with wake-breathing patterns. OBJECTIVE: We set up a daily life study to investigate the feasibility of aerosol administration by means of pMDI-spacer in sleeping young children. DESIGN: Over a period of 3 weeks, 30 children (age range, 6 to 23 months) with recurrent wheeze daily inhaled 1 puff of budesonide aerosol (200 mug) while awake and 1 puff during sleep. Filters positioned between the chamber and the facemask trapped the budesonide aerosol. Parents scored the child's asthma symptoms, degree of cooperation, and feasibility of administration on diary cards. RESULTS: In 69% of the sleep administrations, the children woke up, and in 75% of these cases the children were distressed. The mean filter dose (expressed as the percentage of the nominal dose) while awake was 47%, and during sleep it was 16% (p = 0.007). The median within-subject dose variability while awake was 50%, and during sleep it was 110% (p = 0.007). CONCLUSION: Aerosol administration by means of pMDI-spacer during sleep offers no advantage and is not a feasible treatment option in most young children.

PMID

16899849 [PubMed - indexed for MEDLINE]

Tipo di studio

Osservazionale

Livello di evidenza

2+

Commento

Somministare l'aerosol con lo spray e il distanziatore durante il sonno del bambino piccolo non offre alcun vantaggio e spesso non risulta possibile, perchè il lattante si sveglia

Titolo del documento

Aerosol therapy: the special need of young children.

Autori e Nazionalità

Janssenss HM, Tiddens HA. Olanda

Fonte bibliografica

Paediatr Respir Rev 2006; 7 Suppl 1:S83-5

Lingua

Inglese

Abstract

One third of young children are distressed during inhalation therapy. It has been suggested that administration during sleep could be a good alternative for these children. A laboratory study in our department using an infant upper airway model showed significantly higher lung doses from a pressured metered-dose inhaler (pMDI)-spacer for sleep-breathing patterns compared with wake-breathing patterns. OBJECTIVE: We set up a daily life study to investigate the feasibility of aerosol administration by means of pMDI-spacer in sleeping young children. DESIGN: Over a period of 3 weeks, 30 children (age range, 6 to 23 months) with recurrent wheeze daily inhaled 1 puff of budesonide aerosol (200 mug) while awake and 1 puff during sleep. Filters positioned between the chamber and the facemask trapped the budesonide aerosol. Parents scored the child's asthma symptoms, degree of cooperation, and feasibility of administration on diary cards. RESULTS: In 69% of the sleep administrations, the children woke up, and in 75% of these cases the children were distressed. The mean filter dose (expressed as the percentage of the nominal dose) while awake was 47%, and during sleep it was 16% (p = 0.007). The median within-subject dose variability while awake was 50%, and during sleep it was 110% (p = 0.007). CONCLUSION: Aerosol administration by means of pMDI-spacer during sleep offers no advantage and is not a feasible treatment option in most young children.

 

PMID

16899849 [PubMed - indexed for MEDLINE]

Tipo di studio

Revisione narrativa

Livello di evidenza

4

Commento

Un'ottimale deposizione dell'aerosol può essere raggiunta con una buona aderenza della mascherina al viso, una buona collaborazione del paziente e un respiro tranquillo

Titolo del documento

Bronchodilators via metered-dose inhaler with spacer in the pediatric emergency department: what is the dosage ?

Autori e Nazionalità

Benito Fernandez J, Trebolazabala QN, Garriz LM, Raso MS, Diaz GC. Spagna

Fonte bibliografica

An Pediatr 2006;64:46-51

Lingua

Inglese

Abstract

INTRODUCTION: Bronchodilators administrated through a metered-dose inhaler (MDI) with spacer are as effective as nebulizers in the treatment of acute asthma exacerbations in childhood. However, consensus is lacking on the most suitable dosage. OBJECTIVE: To assess the effectiveness of distinct salbutamol and terbutaline doses delivered via an MDI with spacer for the treatment of acute asthma in the pediatric emergency department. METHODS: This was a prospective, double-blind randomized study. All consecutive children (n = 324) between 2 and 14 years of age with acute asthma exacerbations treated in the pediatric emergency department between October 1 and November 30, 2004, were included. Two treatment groups were established: one group received a number of puffs equivalent to half the child's weight (1 puff of salbutamol = 100 microg and 1 puff of terbutaline = 250 microg) and the other group received a number of puffs equivalent to one-third of the child's weight. RESULTS: Three hundred twenty-four episodes were studied; there were 164 children in the first group and 160 in the second. There were no significant differences between the two groups in the mean (6 SD) age (58.34 +/- 34.72 vs 66.04 +/- 36.45 months), arterial oxygen saturation (95.49 +/- 1.93 vs 95.56 +/- 1.97) or pulmonary score (4.04 +/- 1.55 vs 3.97 +/- 1.51) at recruitment and after treatment in the emergency department (arterial oxygen saturation [96.34 +/- 1.60 vs 96.18 +/- 1.77], pulmonary score [1.87 +/- 1.33 vs 1.64 +/- 1.31]). The number of doses administered (2.17 +/- 0.91 vs 2.24 +/- 1.00) and the hospitalization rate (8.56 % vs 6.87 %) were also similar in both groups. CONCLUSIONS: The distinct bronchodilator doses administered via an MDI with spacer showed similar effectiveness. These findings should contribute to a reevaluation of the use of high doses of bronchodilators, at least in most acute asthma exacerbations in children.

 

PMID

16539916 [PubMed - indexed for MEDLINE]

Tipo di studio

Osservazionale

Livello di evidenza

3

Commento

Qual'è il dosaggio ottimale del broncodilatatore somministrato con lo spray e il distanziatore nell'attacco acuto d'asma. Questo articolo propone delle risposte.

Titolo del documento

Metered-dose inhaler with spacer vs nebulization for severe and potentially severe acute asthma treatment in the pediatric emergency department.

Autori e Nazionalità

Sannier N, Timsit S, Cojocaru B, Leis A, Wille C, garel D, Bocquet N, Chéron G. Francia

Fonte bibliografica

Arch Pediatr 2006;13:238:44.

Lingua

Francese

Abstract

OBJECTIVE: To compare treatment with beta 2 agonist delivered either by a spacer device or a nebulizer in children with severe or potentially severe acute asthma. METHODS: In this randomized trial, children 4 to 15 years, cared for in the emergency department for severe or potentially severe acute asthma, received 6 times either nebulizations of salbutamol (0.15mg/kg) or puffs of a beta 2 agonist (salbutamol 50 microg/kg or terbutaline 125 microg/kg). The primary outcome was the hospitalization rate. Secondary outcomes included percentage improvement in Bishop score, in PEF, SaO(2), respiratory and heart rates, side effects, length of stay and relapses 10 and 30 days later. RESULTS: Groups did not differ for baseline data. There were no significant differences between the 2 groups (nebulizer N=40, spacer N=39) for baseline characteristics before emergency department consultation except for length of acute asthma in the spacer group. Clinical evolution after treatment, hospitalization rate, relapse were similar including the more severe subgroup. In the spacer group, tachycardia was less frequent (P<0.02). The overall length of stay in the emergency department was significantly shorter (148+/-20 vs 108+/-13 min, P<10(-9)). CONCLUSIONS: The administration of beta 2 agonist using a metered-dose inhaler with spacer is an effective alternative to nebulizers for the treatment of children with severe or potentially severe acute asthma in the emergency department. Time gained can be used for asthma education.

 

PMID

16423517 [PubMed - indexed for MEDLINE]

Tipo di studio

Randomizzato

Livello di evidenza

1+

Commento

Un altro tassello del confronto spray con il distanziatore vs nebulizzatore nel trattamento dell'accesso acuto d'asma tramite broncodilatatori

Titolo del documento

Holding chambers versus nebulisers for inhaled steroids in chronic asthma.

Autori e Nazionalità

Cates CJ, Adams N, Bestall J. Gran Bretagna.

Fonte bibliografica

Cochrane Database Syst Rev 2006;(1):CD001491.

Lingua

Inglese

Abstract

BACKGROUND: Inhaled corticosteroids are available in the form of a suspension for nebulisation, although the role of this mode of therapy in the treatment of chronic asthma is still unclear. OBJECTIVES: To assess the efficacy and safety of inhaled corticosteroids delivered via nebuliser versus holding chamber for the treatment of chronic asthma. SEARCH STRATEGY: We searched the Cochrane Airways Group Trial Register (1999) and reference lists of articles. We contacted the authors of studies and pharmaceutical companies for additional studies and hand-searched the British Journal of Clinical Research, European Journal of Clinical Research and major respiratory society meeting abstracts (1997-1999). SELECTION CRITERIA: Randomised controlled trials comparing nebuliser to holding chamber in the delivery of inhaled corticosteroids for the treatment of chronic asthma. All age groups of patients were considered. Two reviewers assessed articles for inclusion; two reviewers independently assessed included studies for methodological quality. DATA COLLECTION AND ANALYSIS: One reviewer extracted data; authors were contacted to clarify missing information. Quantitative analyses were undertaken using Review Manager 4.1 with MetaView 3.1. MAIN RESULTS: Two studies were selected for inclusion (63 subjects), both concerned adults. Methodological quality was variable. Due to design differences it was not appropriate to pool the studies. The single high quality study compared budesonide 2000-8000 mcg delivered via Pari Inhalier Boy jet nebuliser with inspiration-only inhalation to budesonide 1600 mcg via large volume spacer. The nebuliser delivery led to higher morning peak expiratory flow values (25 L/min p<0.01), higher evening values (30L/min, p<0.01), lower rescue beta2 agonist use and symptom scores compared to the holding chamber delivery. REVIEWER'S CONCLUSIONS: Budesonide in high dose delivered by the particular nebuliser used in the only double-blinded study that could be included in this review was more effective than budesonide 1600 mcg via a large volume spacer. However, it is not clear whether this was an effect of nominal dose delivered or delivery system. Cost, compliance and patient preference are important determinants of clinical effectiveness that have not been assessed. Future studies are needed to evaluate the relative effectiveness of inhaled corticosteroids delivered by different combinations of nebuliser/compressor compared to holding chamber. Moreover, further studies assessing these delivery methods are needed in infants and pre-school children, as these are groups that are likely to be considered for treatment with nebulised corticosteroids.

PMID

11405994 [PubMed - indexed for MEDLINE]

Tipo di studio

Revisione Sistematica 

Livello di evidenza

1+

Commento

 

Titolo del documento

Determinants of patient adherence to an aerosol regimen.

Autori e Nazionalità

Rau JL 

Fonte bibliografica

Respir Care 2005; 50:1346-1356

Lingua

Inglese

Abstract

Patient adherence with prescribed inhaled therapy is related to morbidity and mortality. The terms "compliance" and "adherence" are used in the literature to describe agreement between prescribed medication and patient practice, with "adherence" implying active patient participation. Patient adherence with inhaled medication can be perfect, good, adequate, poor, or nonexistent, although criteria for such levels are not standardized and may vary from one study to another. Generally, nonadherence can be classified into unintentional (not understood) or intentional (understood but not followed). Failing to understand correct use of an inhaler exemplifies unintentional nonadherence, while refusing to take medication for fear of adverse effects constitutes intentional nonadherence. There are various measures of adherence, including biochemical monitoring of subjects, electronic or mechanical device monitors, direct observation of patients, medical/pharmacy records, counting remaining doses, clinician judgment, and patient self-report or diaries. The methods cited are in order of more to less objective, although even electronic monitoring can be prone to patient deception. Adherence is notoriously higher when determined by patient self-report, compared to electronic monitors. A general lack of adherence with inhaled medications has been documented in studies, and adherence declines over time, even with return clinic visits. Lack of correct aerosol-device use is a particular type of nonadherence, and clinician knowledge of correct use has been shown to be imperfect. Other factors related to patient adherence include the complexity of the inhalation regimen (dosing frequency, number of drugs), route of administration (oral vs inhaled), type of inhaled agent (corticosteroid adherence is worse than with short-acting beta2 agonists), patient awareness of monitoring, as well as a variety of patient beliefs and sociocultural and psychological factors. Good communication skills among clinicians and patient education about inhaled medications are central to improving adherence.

 

PMID

16185370 [PubMed - indexed for MEDLINE

Tipo di studio

Esposizione narrativa

Livello di evidenza

4

Commento

Che differenza c'è fra compliance e aderenza alla terapia.  Quali sono i fattori che influenzano l'aderenza della terapia inalatoria 

Titolo del documento

Randomized controlled trial of salbutamol aerosol therapy via metered dose inhaler-spacer vs jet nebulizer in young children with wheezing

Autori e Nazionalità

Deerojanawong J, Manuyakorn W, Prapphal N, Harnruthakorn C, Sritippayawan S, Samransamruajkit R. Tailandia 

Fonte bibliografica

Pediatr Pulmonol 2005;39:466-72 

Lingua

Inglese

Abstract

The jet nebulizer is a common device used for administering aerosol medication in young children. However, compared to a metered dose inhaler-spacer (MDI-spacer), it takes more time and personnel. This study aimed to compare the efficacy of salbutamol aerosol therapy given via these two devices in young wheezing children. A prospective randomized, double-blind, placebo-controlled trial was performed in children up to 5 years old who had acute wheezing and were admitted to the Department of Pediatrics, King Chulalongkorn Memorial Hospital. Patients were randomly divided into two groups. The first group received 2 puffs of placebo via MDI-spacer, followed by 0.15 mg/kg salbutamol respiratory solution via jet nebulizer. The second group received 2 puffs (100 microg/puff) of salbutamol via MDI-spacer, followed by placebo via jet nebulizer. Clinical scores and tidal breathing pulmonary function test were evaluated before and after treatment. Pulmonary function parameters included those derived from flow volume loops (volume to peak tidal expiratory flow over total expiratory volume, V(PTEF)/V(E); time to peak tidal expiratory flow over total expiratory time, T(PTEF)/T(E); and ratio of tidal expiratory flow at 25% remaining expiration to peak expiratory flow, 25/PF), compliance (Crs), and resistance (Rrs) of the respiratory system. The efficacy of both methods was compared by using analysis of covariance. Forty-seven wheezing children were studied (24 received salbutamol via MDI-spacer, and 23 received it via jet nebulizer). There was no statistical difference between the two groups regarding clinical scores and all pulmonary function parameters. However, heart rate was significantly increased after treatment in the jet nebulizer group when compared to those in the MDI-spacer group (P = 0.004). In conclusion, the efficacy of salbutamol aerosol therapy via MDI-spacer compared to jet nebulizer in young wheezing children was not different in terms of clinical score and postbronchodilator pulmonary function parameters. However, salbutamol aerosol therapy via jet nebulizer significantly increased the heart rate when compared to the MDI-spacer.

PMID

15786440 [PubMed - indexed for MEDLINE]

Tipo di studio

Randomizzato, in doppio cieco

Livello di evidenza

1+

Commento

Confronto spray con il nebulizzatore vs nebulizzatore per somministrare i broncodilatatori nell'asma acuto nei bambini dell'età prescolare

Titolo del documento

The role of the MDI and DPI in Pediatric patients: "children are not just miniature adults"

Autori e Nazionalità

Ahrens RC. Usa

Fonte bibliografica

Respir Care 2005;50:1323-1330

Lingua

Inglese

Abstract

Metered-dose inhalers (MDIs) and dry powder inhalers play an important role in the treatment of asthma in children of all ages. Yet these devices, which were originally developed for use in adults, interact differently with children. Through childhood there are progressive changes in pharmacokinetic handling and pharmacodynamic effects of inhaled antiasthmatic drugs, in the efficiency and distribution of aerosolized drugs in the respiratory tract, and in the patient's ability to successfully use aerosol devices. This, in turn, produces changes in potential for producing efficacy and adverse effects, and in the balance between risk and benefit. These differences from adults are greatest for children under 4-5 years of age, who are unable to use DPIs or unassisted MDIs, and who therefore must rely on nebulizers and MDIs with valved holding chambers for inhaled drug delivery. Unfortunately, there are no drugs approved for delivery via MDI (with holding chamber) in children under 4 years of age, and there are insufficient data to ensure that many of the available drug-MDI-holding-chamber combinations are both safe and effective. In particular, the potential for effects of inhaled corticosteroids on growth are insufficiently studied in this age group and remains a concern. It is likely that the risk of adverse effects on growth are different for each of the many possible MDI/valved-holding-chamber combinations.

PMID

16185368 [PubMed - indexed for MEDLINE]

Tipo di studio

Revisione narrativa

Livello di evidenza

4

Commento

Differenze fra adulti e bambini riguardo alle modalità di deposizione nelle vie aeree dei farmaci inalatori

Titolo del documento

True device compliance: the need to consider both comptence and contrivance.

Autori e Nazionalità

Brennan VK, Osman LM, Graham H, Critchlow A, Everard ML.

Fonte bibliografica

Respir Medicine 2005;99:97-102

Lingua

Inglese

Abstract

Inability to use inhalers effectively is known to adversely affect the delivery of drug. It is assumed that increasing competence to use inhalers will lead to improved drug delivery. However many subjects appear competent (are able to use a device effectively) but contrive to use the device in a sub-optimal way in routine use. This study aimed to explore levels of True device compliance, that is the extent to which devices are used effectively in routine use, and to explore the influences of age and device on this parameter. The ability of 53 asthmatic patients aged 1-88 years to use their corticosteroid inhaler was assessed by a single investigator. In addition information regarding patient behaviour in routine practice was explored in a structured interview. True device compliance was defined to occur when a subject was rated competent and did not report contrivance. Competence was related to device type. All subjects using a holding chamber [pMDI + HC] (N = 21) or breath activated inhaler (N = 5) could demonstrate an adequate technique compared with only 9 (47%) of those prescribed a pMDI. However only 4 (19%) prescribed a pMDI + HC were true device compliant with the majority regularly using the pMDI alone while (42%) of those prescribed a pMDI were True device compliant. Since 82% of patients over 65 were prescribed pMDI alone, and 92% of patients up to 5 years were prescribed pMDI + HC, True device compliance was low among both groups. Only 33% of patients over 65 prescribed pMDIs were able to use them competently. Lack of competence, particularly in the elderly, and contrivance, particularly common amongst those using holding chambers, are two important but independent impediments to effective inhaled therapy.

PMID

15672856 [PubMed - indexed for MEDLINE]

Tipo di studio

osservazionale

Livello di evidenza

3

Commento

Mancanza di competenze e rifiuto sono comuni tra i pazienti che utilizzano i distanziatori

Titolo del documento

Nebulizers or pressurized metered dose inhalers in the treatment of asthma exacerbations.

Autori e Nazionalità

Radzik D, Peroni DG, Pescollderung L, Piacentini GL, Chatzmichail A, Boner

Fonte bibliografica 

Allergy Asthma Proc 2005;26:207-209

Lingua

Inglese

Abstract

The use of inhaled beta2-agonists delivered by a metered-dose inhaler (MDI) with a holding chamber (spacer) actually is considered the best treatment for childhood acute asthma. However, its use in daily practice still seems rather limited. The aim of this study was to investigate, using a questionnaire, the use of a nebulizer or MDI as the first-line method for delivering inhaled beta2-agonists in children with acute asthma. A questionnaire was developed and distributed to 22 pediatric departments and to 131 family pediatricians (FPs) in northeast Italy. We showed that in the hospitals the episodes of acute asthma usually were treated with bronchodilators administered by wet nebulization (95.45%). This was the case also for FPs (70.9%). However, 29.1% of FPs usually advised the use of an MDI/holding chamber to children with acute asthma. Despite the established efficacy of inhaled beta2-agonists administrated with an MDI compared with wet nebulization in acute asthma, this practice still is rather limited. The use of wet nebulization was more evident in hospital settings compared with community medicine. Emergency room visits may represent a missed opportunity to promote an effective method of delivering bronchodilators in childhood asthma.

 

PMID

16119036 [PubMed - indexed for MEDLINE]

Tipo di studio

Osservazionale

Livello di evidenza

3

Commento

il distanziatore viene usato di preferenza per somministrare i broncodilatatori nell'attacco acuto d'asma solo da 1 U.O di Pediatria su 22 del Veneto e Trentino Alto Adige e da 1 Pediatria di famiglia su 3

Titolo del documento

Key issues in inhalation technique in children. Curr Med Res Opinion 2005; Suppl 4:S27-S32

Autori e Nazionalità

Brand PL. Olanda

Fonte bibliografica

Curr Med Res Opinion 2005; Suppl 4 :S27-S32

Lingua

Inglese

Abstract

In order to achieve asthma control it is essential that children receive the appropriate education and training pertaining to the management of their disease, are prescribed the correct medication according to severity, and most importantly, are prescribed the correct inhaler to ensure medication is deposited in their lungs. There are three major misconceptions which physicians and patients have regarding the use of inhalers in children. Firstly, that the nebulizer is more effective than a pressurised metered dose inhaler (pMDI) plus spacer in treating acute asthma in children. Secondly that using an inhaler correctly is easy, and lastly that correct use of the inhaler, once taught, persists over time. However, recent studies have shown that these conceptions are false. Firstly, comparable efficacy is achieved by treatment with inhaled corticosteroids or bronchodilators delivered through a nebulizer and a pMDI plus spacer, both when used to treat acute asthma and for maintenance therapy. Secondly, contrary to general opinion, using an inhaler correctly is difficult for children. Many children with asthma use their inhaler devices incorrectly, even after instruction for correct use of the inhaler. Thirdly, correct inhalation technique deteriorates over time; and inhalation instructions, therefore, should be given repeatedly to achieve and maintain correct inhalation technique in asthmatic children. The profile of the ideal inhaler comprises good drug deposition in the lower airways, deliverance of a consistent dose, being easy to teach and to use correctly, and being small in size and convenient to handle. It should also be multidose, require a low inspiratory airflow for activation, provide feedback to patients on correct use of the inhaler, be re-usable, have an appealing design and feel, and have a reliable dose counter which may help to monitor the patient's compliance. The Novolizer device, a new multidose dry powder inhaler (DPI), shows many of these characteristics making it potentially very suitable for children with asthma.

PMID

16138942 [PubMed - indexed for MEDLINE]

Tipo di studio

Revisione narrativa

Livello di evidenza

4

Commento

Quali sono le chiavi per una corretta tecnica inalatoria ?

Titolo del documento

Evaluation of particle size distribution of albuterol sulfate hydrofluoroalcane administered via metered-dose inhaler with or without holding chambers.

Autori e Nazionalità

Crim C, Holmes M, Lee B, Cavanaugh R,Lincourt W. Usa 

Fonte bibliografica

Ann Allergy Asthma immunol 2005;94;80-85.

Lingua

Inglese

Abstract

BACKGROUND: Administration of inhaled medications via metered-dose inhaler (MDI) to pediatric patients younger than 4 years usually requires use of a holding chamber or spacer with an attached face mask. OBJECTIVE: To determine the particle size distribution and overall dose of albuterol from the albuterol sulfate hydrofluoroalkane delivered in conjunction with 2 US-marketed valved holding chambers (VHCs) compared with the dose delivered via MDIs without VHCs. METHODS: Cascade impaction methods with high-performance liquid chromatography were used to evaluate the fine particle mass (FPM) of albuterol administered without and with the use of 2 commercially available VHCs. RESULTS: Particle size distributions for the 2 VHCs and the control were similar. The mean FPM values for the 2 VHCs and the control were 32, 28, and 30 microg, respectively. Statistical comparison of the FPM shows a similar profile when differences from the albuterol hydrofluoroalkane without a spacer were evaluated. CONCLUSIONS: In vitro results obtained under these test conditions demonstrate that all the FPM values for the VHCs tested were within 15% of the control range, a difference that is unlikely to be clinically meaningful. These results do not warrant a change in the recommended dose of albuterol hydrofluoroalkane administered when using the VHCs tested. The use of an MDI in conjunction with a VHC provides a reasonable therapeutic approach for administration of albuterol hydrofluoroalkane to young children and other patients who have difficulty administering the MDI alone.

PMID

15702821 [PubMed - indexed for MEDLINE]

Tipo di studio

Osservazionale

Livello di evidenza

2+

Commento

 

Titolo del documento

Aerosol delivery to young children by pMMDI-spacer: is facemask design important ?  

Autori e Nazionalità

Esposito-Festen J, Ates B, van Vliet F, Hop W, Tiddens H. Olanda 

Fonte bibliografica

Pediatr Allergy Immunol 2005;16:348-353

Lingua

Inglese

Abstract

This study aimed at identifying in a daily-life setting the influence of facemask design on drug delivery via a spacer to young children. In a 4-week randomized crossover study, 24 children (7-23-months old) with recurrent wheeze tested the AstraZeneca, Galemed, and Hans Rudolph facemask combined with the NebuChamber at home. Each mask was tested twice daily for seven consecutive days. Filters positioned between the NebuChamber and facemask trapped the budesonide aerosol (200 microg, Pulmicort). Parents were asked to score the child's degree of cooperation during administration on diary cards. The administration procedure was evaluated through video recordings. Mean filter dose (standard deviation (s.d.)), expressed as % of nominal dose, was 39% (14), 47% (12), and 42% (11) for the AstraZeneca, the Galemed and the Hans Rudolph mask, respectively. Irrespective of the degree of cooperation, the Galemed mask gave significantly higher mean filter doses than the other masks (level of significance) (p < 0.045). Median (range) within-subject dose variability, expressed, as coefficient of variation (CV), was 37% (19-255), 32% (9-114), and 30% (9-115) for the AstraZeneca mask, the Galemed mask and the Hans Rudolph mask, respectively, not significant. Dose variability increased with decreasing cooperation for all three masks (p = 0.007). Drug delivery to young children with recurrent wheeze by means of the NebuChamber can be enhanced using the Galemed facemask. Dose variability seems to be independent of facemask design but mainly depends on cooperation

PMID

15943599 [PubMed - indexed for MEDLINE]

Tipo di studio

Osservazionale

Livello di evidenza

3

Commento

Per gli autori di questo studio svolge un ruolo più importante nell'influenzare la quota di farmaco inalata, la collaborazione del bambino rispetto al disegno della maschera

Titolo del documento

An evaluation of children's metered-dose inhaler technique for asthma medications.

Autori e Nazionalità

Burkhart PV, Rayens MK, Bowman RK. Usa

Fonte bibliografica

Nurse Clin North Am 2005;40:167-182. 

Lingua

Inglese

Abstract

Regardless of the medication delivery system, health care providers need to teach accurate medication administration techniques to their patients, educate them about the particular nuances of the prescribed delivery system (eg, proper storage), and reinforce these issues at each health encounter. A single instruction session is not sufficient to maintain appropriate inhaler techniques for patients who require continued use. Providing written steps for the administration technique is helpful so that the patient can refer to them later when using the medication. The National Heart, Lung, and Blood Institute's "Practical Guide for the Diagnosis and Management of Asthma" recommends that practitioners follow these steps for effective inhaler technique training when first prescribing an inhaler: 1. Teach patients the steps and give written instruction handouts. 2. Demonstrate how to use the inhaler step-by-step. 3. Ask patients to demonstrate how to use the inhaler. Let the patient refer to the handout on the first training. Then use the handout asa checklist to assess the patient's future technique. 4. Provide feedback to patients about what they did right and what they need to improve. Have patients demonstrate their technique again, if necessary.The last two steps should be performed (ie, demonstration and providing feedback on what patients did right and what they need to improve) at every subsequent visit. If the patient makes multiple errors, it is advisable to focus on improving one or two key steps at a time. With improvements in drug delivery come challenges, necessitating that practitioners stay current with new medication administration techniques. Teaching and reinforcing accurate technique at each health care encounter are critical to help ensure medication efficacy for patients with asthma. Since one fifth of children in the study performed incorrect medication technique even after education, checklists of steps for the correct use of inhalation devices, such as those provided in this article, should be given to patients for home use and for use by clinicians to evaluate patient technique at each health encounter.

PMID

15733954 [PubMed - indexed for MEDLINE]

Tipo di studio

Osservazionale

Livello di evidenza

2+

Commento

In quale modo insegnare ai pazienti la tecnica d'uso corretta dei distanziatori ?  Per la risposta vedi la sezione FAQ

Titolo del documento

Determining factors of aerosol deposition for four pMDI- spacer combinations in an infant upper airway model

Autori e Nazionalità

Janssens HM, Krijgsman A, Verbraank TF, Hop WC, de Jongste JC, Tiddens HA.Olanda

Fonte bibliografica

J Aerosol Med 2004;17(1):51-56

Lingua

Inglese

Abstract

The aim of this study was to measure and compare the influence of tidal volume (Vt) respiratory rate (RR) and pMDI/spacer combination on aerosol deposition of 4 pMDI/spacer combinations, which are used for infants. An anatomically correct upper airway model of a 9-month-old infant was connected to a breathing simulator. Sinusoidal breathing patterns were simulated with; duty cycle T(i)/T(tot) = 0.42, Vt: 25, 50, 75, 100, 150, 200 ml (RR: 30 breaths/min); and RR: 20, 30, 42, 60, 78 breaths/min (Vt: 100 mL). pMDI/Spacers tested were: budesonide 200 microg/Nebuchamber, fluticasone 125 microg/Babyhaler and both budesonide and fluticasone with Aerochamber. Plastic spacers were detergent coated to reduce electrostatic charge. Spacer-output and lung dose were measured by a filter positioned between spacer and facemask or between model and breathing simulator. Particle size distribution of lung dose was assessed with an impactor during simulated breathing. Spacer-output was significantly positively correlated with Vt for all pMDI/spacers (all R > 0.77, p < 0.001), but not correlated with RR. Lung doses initially increased from Vt = 25 to 50 mL (Nebuchamber, Aerochamber) or to 100 mL (Babyhaler) and then decreased, with increasing Vt and RR (R: -0.98 to -0.82, p < 0.001). Lung doses of fluticasone were 1.5-6-fold higher compared with budesonide, irrespective of spacer type (p < 0.001). MMAD decreased with increasing Vt and RR. Dose to the lungs of particles <2.1 microm was independent of Vt and RR. Lung dose decreases with increasing inspiratory flow (increasing Vt or RR) by increasing impaction of coarse particles in the upper airways. Deposition of particles <2.1 microm is relatively flow independent. When electrostatic charge of spacers is reduced, lung dose is pMDI dependent and spacer independent.

PMID

15120013 [PubMed - indexed for MEDLINE]

Tipo di studio

Oseervazionale

Livello di evidenza

3

Commento

Titolo del documento

Comparison of efficiency and preference of metal and plastic spacers in preschool children.

Autori e Nazionalità

Amirav I, Tiosano T, Chamny S, Chirurg S, Oren S, Grossman Z, Kahan E, Newhouse MT, Mansour Y. Israele 

Fonte bibliografica

Annals Allergy Asthma Immunol 2004;93:249-252

Lingua

Inglese

Abstract

BACKGROUND: The metal NebuChamber valved holding chamber (VHC) has gained wide acceptance among children with asthma. Due to its nonelectrostatic properties and larger volume, the 250-mL, metal NebuChamber delivers a greater mass of aerosol to a filter at the mouth compared with the commonly used 150-mL polypropylene AeroChamber VHC. Such in vitro results have been used to suggest that this may provide increased efficacy with the NebuChamber. No comparative efficacy data exist for preschool children with asthma. OBJECTIVE: To compare efficiency and preference of metal and plastic spacers in preschool children. METHODS: Children with mild-to-moderate persistent asthma received 200 microg of budesonide twice daily by NebuChamber or AeroChamber, both with the mask provided in a randomized, 2-month, crossover trial. Symptom diary cards, beta-agonist use, and preference by children and parents were compared. RESULTS: Thirty children (mean +/- SD age, 4.3 +/- 0.3 years) completed the study. There was no difference between the AeroChamber and NebuChamber in clinical efficacy outcomes. There was no difference between the AeroChamber and NebuChamber in parents' view of ease of use, design, acceptability by the children, and overall satisfaction. CONCLUSIONS: Despite a greater total dose delivered to the mouth, the NebuChamber appears no more effective than the AeroChamber and it is not preferred by patients or parents. More parents chose to continue to use the NebuChamber after the study.

PMID

15478384 [PubMed - indexed for MEDLINE]

Tipo di studio

Osservazionale

Livello di evidenza

2+

Commento

Nonostante con la Nebuchamber di metallo la dose di budesonide che arrivi alla bocca è maggiore di quella che si ottiene  con l'Aerochamber non c'è differenza di efficacia fra i due distanziatori. Il secondo è quello preferito dai bambini e dai loro genitori

Titolo del documento

Redesigned face mask improves "real life" aerosol delivery for Nebuchamber. 

Autori e Nazionalità

Amirav I, Mansour Y, Mandelberg A, Bar-Ilan I, Newhouse MT.Israele

Fonte bibliografica

Pediatr Pulmonol 2004;37:172-177. 

Lingua

Inglese

Abstract

The currently available facemask interface for the Nebuchamber (N) valved-holding chamber (VHC) provides a very poor seal to the face, which, on average, decreases the aerosol dose and was previously shown to increase the variability of aerosol delivery. The efficiency of a redesigned mask (RD) for the Nebuchamber with a potentially better seal was compared to the standard mask (SM) supplied with the N in a randomized real-life crossover clinical trial. Twenty children (mean age, 26 +/- 10 months) were randomized to use the Nebuchamber for 1 week with the old mask and then for another week with the newer mask, and vice versa. Filters, changed daily, inserted between the mask and the VHC, trapped the delivered drug (budesonide). The dose of budesonide was quantified by high-performance liquid chromatography (HPLC). Use of the redesigned mask improved aerosol delivery to the filter by 30%, compared to the SM (mean 28.1 +/- 7.7% of nominal dose with RD vs. 21.6 +/- 9.6% with SM, P = 0.017). The relatively high within-subject variability in aerosol delivery (36-38%) did not change, however. Facemasks are arguably the most important determinants of aerosol delivery. The newly developed RD for the Nebuchamber proved to be considerably more efficient than the SM for aerosol delivery to young children. Patient-related factors may be more important with respect to the variability observed

PMID

14730663 [PubMed - indexed for MEDLINE]

Tipo di studio

Osservazionale

Livello di evidenza

2+

Commento

La maschera della Nebuchamber di metallo permette una scarsa adesione al volto del paziente con una grande variabilità della dose inalata. Dovrebbe pertanto essere ridisegnata

Titolo del documento

Beta-agonists through metered-dose inhaler with valved holding chamber versus nebulizer for acute exacerbation of wheezing or asthma in children under 5 years og age: a systematic review with meta-analysis

Autori e Nazionalità

Castro-Rodriguez JA, Rodrigo GJ. Cile

Fonte bibliografica

J Pediatr 2004;145(2):172-7

Lingua

Inglese

Abstract

OBJECTIVE: To compare the efficacy of beta-agonists given by metered-dose inhaler with a valved holding chamber (MDI+VHC) or nebulizer in children under 5 years of age with acute exacerbations of wheezing or asthma in the emergency department setting. STUDY DESIGN: Published (1966 to 2003) randomized, prospective, controlled trials were retrieved through several different databases. The primary outcome measure was hospital admission. RESULTS: Six trials (n=491) met criteria for inclusion. Patients who received beta-agonists by MDI+VHC showed a significant decrease in the admission rate compared with those by nebulizer (OR, 0.42; 95% CI, 0.24-0.72; P=.002); this decrease was even more significant among children with moderate to severe exacerbations (OR, 0.27; 95% CI, 0.13-0.54; P=.0003). Finally, measure of severity (eg, clinical score) significantly improved in the group who received beta-agonists by MDI+VHC in comparison to those who received nebulizer treatment (standardized mean difference, -0.44; 95% CI, -0.68 to -0.20; P=.0003). CONCLUSIONS: The use of an MDI+VHC was more effective in terms of decreasing hospitalization and improving clinical score than the use of a nebulizer in the delivery of beta-agonists to children under 5 years of age with moderate to severe acute exacerbations of wheezing or asthma

PMID

15289762 [PubMed - indexed for MEDLINE]

Tipo di studio

Revisione Sistematica con Meta-analisi

Livello di evidenza

1+

Commento

Per approfondire l'argomento si consigliano gli articoli pubblicati sulla RIAP  del mese di giugno 2004, agosto 2004 ed ottobre 2004

Titolo del documento

Le treatment inhalé en pratique

Autori e Nazionalità

Pham Ti Thuong, Le Bourgeois M, de Blic J. Scheimann P. Francia

Fonte bibliografica

Archives de pédiatrie 2004;11:1377-1383

Lingua

Francese

Abstract

The modalities of an inhaled treatment depends on the characteristics of the aerosol, on the age of the child, and mainly on the inhalatory system. Before the age of 8 years, the pressurised metered dose inhaler must be used together with a spacer device. Above this age, the use of a breath-actuated inhaler or of a dry powder inhaler can be proposed. Demonstration and educational instructions will increase the probability of compliance and efficiency of the treatment

PMID

15519840 [PubMed - indexed for MEDLINE]

Tipo di studio

Narrativo

Livello di evidenza

4 (Opinione di un esperto)

Commento

Con lo spray e il distanziatore con il boccaglio la deposizione polmonare dell'aerosol è del 6% nel bambino e del 2% quando si usa il distanziatore con la maschera (0.4% in caso di pianto)

Titolo del documento

Inhalers in asthma management: is demonstration the key to compliance ?

Autori e Nazionalità

Fink JB. USA

Fonte bibliografica

Respir Care 2005;50(5):598-600

Lingua

Inglese

Abstract

Vengono riportati alcuni principi generali per aumentare la compliance all'uso dei device nell'asma

PMID

PMID: 15871751 [PubMed - indexed for MEDLINE]

Tipo di studio

Editoriale

Livello di evidenza

4

Commento

Il medico deve consigliare al paziente di portare con sè il device durante le visite di controllo e controllare con una dimostrazione pratica la sua competenza

Titolo del documento

Inhaler therapy. What it means for children with asthma.

Autori e Nazionalità

Parsons K, Worrall G, Knight J, Hewitt D. Canada

Fonte bibliografica

Can Fam Physician 2004;50:1102-8.

Lingua

Inglese

Abstract

OBJECTIVE: To investigate what inhaler therapy means for children with asthma and to identify problems and concerns children experience with inhalers. DESIGN: Qualitative research design. SETTING: A community-based family practice in rural Newfoundland. PARTICIPANTS: Seventeen children, aged 5 to 16, who had been diagnosed with mild or moderate asthma and were being prescribed inhaled steroids or bronchodilators. METHOD: Two in-depth interviews with each of a purposive sample of participants were analyzed by the selective or highlighting approach. MAIN FINDINGS: Common positive themes were identified: inhalers were easy to use, and medication was necessary for good quality of life. Common negative themes were simply forgetting, inconvenient and annoying, only-as-needed approach, medication does not work well anyway, and side effects. CONCLUSION: Inhaler therapy had both positive and negative meaning for children. Although inhaled medications were seen as very important for good quality of life when taken regularly, most children wanted to use them only as needed for symptom control. Children knew the importance of inhaler therapy but still complied poorly.

PMID

15455809 [PubMed - indexed for MEDLINE]

Tipo di studio

Osservazionale

Livello di evidenza

3

Commento

I bambini riconoscono l'importanza della terapia inalatoria, ma hanno una scarsa compliance

Titolo del documento

A new asthma spacer device to improve compliance in children: a pilot study 

Autori e Nazionalità

Chaney G, Clements B, Landau L, Bulsara M, Watt P.  Australia

Fonte bibliografica

Respirology 2004;9:499-506

Lingua

Inglese

Abstract

OBJECTIVE: This pilot study was designed to compare the acceptance, ease of use, and effects on compliance between currently used spacer devices and the Funhaler--a new small volume spacer device designed to improve adherence to asthma medication in children. METHODOLOGY: A matched questionnaire-based survey was conducted by two interviews of each caregiver by the same person. A total of 32 children were randomly recruited from seven clinics spanning widely differing socioeconomic and geographical areas of Perth, Western Australia. Preschool children taking regular inhaled asthma medication using an existing low volume spacer device and aged between 1.5 and 6 years, took part in the pilot study. Parents completed two matched questionnaires. The first questionnaire was completed at the beginning of the study and the second after 2 weeks' use of the Funhaler spacer. Data collected related primarily to ease of use of the devices, child and parental compliance, and treatment attitudes. During the study, parents were also called at random on one occasion to ascertain whether they had attempted to medicate their child the previous day. RESULTS: Using the Funhaler incentive spacer device, parents reported significantly more success at medicating their children (22/30 always successful) in comparison to using their existing spacer device (3/30). Parental adherence to prescribed frequency and the delivery technique of children were also improved. The children also showed improved satisfaction and willingness to use the device and parents' attitude towards medicating their children was improved with the Funhaler spacer device. CONCLUSIONS: Use of a novel, incentive spacer device (Funhaler) appeared to be associated with increased success and fewer problems in medicating children, improved child and parental adherence, and a more positive attitude towards treatment, suggesting that more extensive long-term efficacy trials with the device are warranted.

PMID

15612962 [PubMed - indexed for MEDLINE]

Tipo di studio

Osservazionale

Livello di evidenza

3

Commento

Un'indagine eseguita tramite un questionario per valutare il gradimento di un nuovo distanziatore (Funhaler) dotato di un meccanismo di incentivazione

Titolo del documento

Electrostatic charge on spacer devices and salbutamol response in young children.

Autori e Nazionalità

Dubus JC, Guillot C, Badier M. Francia

Fonte bibliografica

Int J Pharm 2003;261:159-64

Lingua

Inglese

Abstract

Electrostatic charge on plastic spacer devices may affect the efficacy of inhaled drugs, but its consequences have never been evaluated in asthmatic children with airflow limitation. At the end of a positive metacholine challenge, 64 children (51.3+/-12.9 months, 32 boys, specific airway resistance (SRaw) 257.1+/-56.7% and forced expiratory volume in 1s (FEV(1)) 64.2+/-17.9% of the predicted value) inhaled one puff of hydrofluoroalkane-134a (HFA-134a) salbutamol (Ventoline((R))), and 15min later two other puffs (total dose of 300 microgram), delivered through either a new static Babyhaler((R)) (n=21), a detergent-coated, reduced static, Babyhaler((R)) (n=20), or a metal NES-Spacer((R)) (n=23) equipped with facemask. SRaw and FEV(1) were measured after each treatment and compared between groups by a Kruskal-Wallis test. The first 100 microgram salbutamol induced a 151.7+/-43.9% decrease in SRaw and a 19.9+/-10.6% increase in FEV(1). Additional 200 microgram salbutamol allowed a supplementary decrease of 35.1+/-25.7% in SRaw and increase of 12.1+/-11.8% in FEV(1), without significant difference between the spacer devices. Electrostatic charge on spacer devices does not affect bronchodilation with HFA-134a salbutamol in metacholine-challenged pre-school children. This could be in part explained by the use of supramaximal doses of salbutamol.

PMID

12878405 [PubMed - indexed for MEDLINE]

Tipo di studio

Osservazionale

Livello di evidenza

3

Commento

Studio che esamina le conseguenze delle cariche elettrostatiche in bambini asmatici con broncoostruzione

Titolo del documento

Aerosol therapy and the fighting toddler: is administration duering sleep an alternative ?

Autori e Nazionalità

Janssens H, van der Wiel EC, Verbraak AF, de Jongste JC, Merkus PJ, Tiddens HA. Olanda 

Fonte bibliografica

J Aerosol Med 2003;16:395-400. 

Lingua

Inglese

Abstract

Insufficient cooperation during administration of aerosols by pressurized metered dose inhaler (pMDI)/spacers is a problem in nearly 50% of treated children younger than 2 years. For these children, administration during sleep might be more efficient. However, it is unknown how much aerosol reaches the lungs during sleep. The aim of this study was to determine in vitro the lung dose in young children from a pMDI/spacer during sleep and while being awake. Breathing patterns were recorded by a pneumotachograph in 18 children (age 11 +/- 5.1 months) during sleep and wakefulness. Next, breathing patterns were replayed by a computer-controlled breathing simulator to which an anatomically correct nose-throat model of a 9-month-old child was attached. One puff of budesonide (200 microg) was administered to the model via a metal spacer. Aerosol was trapped in a filter placed between model and breathing simulator. The amount of budesonide on the filter (5 lung dose) was analyzed by HPLC. For each of the 36 breathing patterns, lung dose was measured in triplicate. The sleep breathing patterns had significantly lower respiratory rate and peak inspiratory flows, and smaller variability in respiratory rate, tidal volume, and peak inspiratory flows. Lung dose (mean +/- SD) was 6.5 +/- 3.2 and 11.3 +/- 3.9 microg (p = 0.004) for the wake and sleep breathing pattern, respectively. This infant model-study shows that the lung dose of budesonide by pMDI/spacer is significantly higher during sleep compared to inhalation during wake breathing. Administration of aerosols during sleep might, therefore, be an efficient alternative for uncooperative toddlers.

PMID

14977430 [PubMed - indexed for MEDLINE]

Tipo di studio

Osservazionale

Livello di evidenza

3

Commento

Utilizzando un modello sperimentale gli autori sostengono che il sonno favorirebbe la deposizione polmonare del farmaco: questo risultato è stato però ottenuto in bambini sedati con cloralio idrato, realizzando un pattern ideale di sonno

Titolo del documento

Effect of detergent-coated versus non-coated spacers on bronchodilator response in children with asthma

Autori e Nazionalità

Barben JU, Roberts M, Robertson CF. Australia

Fonte bibliografica

J Paediatr Child Health 2003;39:270-273

Lingua

Inglese

Abstract

OBJECTIVE: Previous studies have demonstrated that coating spacers with ionic detergents minimizes the static charge and thereby improves in vivo drug deposition. The present study aims to examine the effect of coated spacers versus non-coated spacers in the clinical situation. METHODS: A randomized, double-blind study in children with asthma and a ratio of forced expiratory volume in 1 s to forced vital capacity (FEV1/FVC) of < or =72% predicted was carried out. Spirometry was performed at baseline and at 10 min and 20 min after inhalation of two puffs of salbutamol (100 microg/puff) through either a detergent-coated or a non-coated spacer. RESULTS: Fifty children were studied (mean age 11.6 years, range 7-18 years): 26 in the group using coated spacers (CG); and 24 in the group using non-coated spacers (NCG). The mean percentage change in FEV1 from baseline 10 min after inhalation was 18.8% (range 5-50%) in the CG versus 18.5% (range 3-35%) in the NCG. At 20 min after inhalation, the per cent increase in FEV1 was 19.8% (range 0-50%) in the CG versus 19.5% (range 9-35%) in the NCG. There was no significant difference between groups in the percentage change in FEV1 after 10 min (P = 0.91), or after 20 min (P = 0.93). CONCLUSIONS: There was no improvement in bronchodilatation from detergent-coated spacers in the present study, possibly because a maximal bronchodilator response was achieved with the lower output.

PMID

12755932 [PubMed - indexed for MEDLINE]

Tipo di studio

Randomizzato, in doppio cieco

Livello di evidenza

1+

Commento

Gli autori non trovano alcun vantaggio nella risposta al bronciìodilatatore, misurata con il FEV1 fra un distanziatore sottoposto a trattamento antistatico e non. Gli autori ipotizzano che la massima risposta viene raggiunta con una quota di farmaco inferiore a quella utilizzata (è sufficiente poco salbutamolo per ottenere la risposta massimale)

Titolo del documento

Bacterial contamination of spacer devices used by children with asthma.  

Autori e Nazionalità

Cohen HA, Cehen Z, kahan E. Israele

Fonte bibliografica

JAMA 2003;290:195-6

Lingua

Inglese

Abstract

Con questa lettera gli autori israeliani segnalano di aver trovato un’alta contaminazione da Pseudomonas speciei sia nel reservoir (23%) sia nella mascherina (13,3%) dei distanziatori “personali” di bambini che utilizzavano routinariamente questa tecnica

PMID

12851272 PubMed 

Tipo di studio

di laboratorio 

Livello di evidenza

Commento

Titolo del documento

Nebulizers vs metered-dose inhalers with spacers for bronchodilator therapy to treat wheezing in children aged 2 to 24 months in a paediatric emergency department.

Autori e Nazionalità

Delgado A, Chou KJ, Silver EJ, Crain EF. Usa.

Fonte bibliografica

Arch Pediatr Adolesc Med 2003;157:76-80.

Lingua

Inglese

Abstract

OBJECTIVE: To determine if administration of albuterol by a metered-dose inhaler with a spacer device is as efficacious as administration of albuterol by nebulizer to treat wheezing in children aged 2 years and younger. DESIGN: Double-blind, randomized, placebo-controlled clinical trial. SETTING: Pediatric emergency department. PATIENTS: From a convenience sample of wheezing children aged 2 to 24 months, 85 patients were enrolled in the nebulizer group and 83 in the spacer group. INTERVENTIONS: The nebulizer group received a placebo metered-dose inhaler with a spacer followed by nebulized albuterol. The spacer group received albuterol by a metered-dose inhaler with a spacer followed by nebulized isotonic sodium chloride solution. Treatments were given every 20 minutes by a single investigator blinded to group assignment. MAIN OUTCOME MEASURES: The primary outcome was admission rate. Pulmonary Index score and oxygen saturation were measured initially and 10 minutes after each treatment. RESULTS: The nebulizer group had a significantly higher mean (SD) initial Pulmonary Index score compared with the spacer group (7.6 [2.5] vs 6.6 [2.0]; P =.002). With the initial Pulmonary Index score controlled, children in the spacer group were admitted less (5% vs 20%; P =.05). Analyses also revealed an interaction between group and initial Pulmonary Index score; lower admission rates in the spacer group were found primarily in children having a more severe asthma exacerbation. CONCLUSION: Our data suggest that metered-dose inhalers with spacers may be as efficacious as nebulizers for the emergency department treatment of wheezing in children aged 2 years or younger.

PMID

12517199 [PubMed - indexed for MEDLINE]

Tipo di studio

Randomizzato

Livello di evidenza

1+

Commento

Spray con il distanziatore vs nebulizzatore per somministrare i broncodilatatori nella terapia dell'attacco acuto d'asma

Titolo del documento

Cough after inhalation of corticosteroids delivered from spacer devices in children with asthma

Autori e Nazionalità

Dubus JC, Mély L, Huiart L, Marguet C, Le Roux P. Francia

Fonte bibliografica

Fundam Clin Pharmacol 2003;17:627-31

Lingua

Inglese

Abstract

Children using a spacer device rather than another device for delivering inhaled corticosteroids (ICS) has been identified as a risk factor for cough immediately after inhalation. The aim of this study was to point out the different factors influencing the occurrence of such lateral side-effects. We studied this local side-effect in 402 asthmatic children (55.6 +/- 34.9 months; 65.6% boys) treated for at least 1 month with beclomethasone dipropionate (n = 331), budesonide (n = 47) or fluticasone propionate (n = 24) delivered from pressurized metered-dose inhalers and small (75.1%) or large volume (24.8%) spacer devices mainly used with face mask (90.7%). A total of 219 patients (54.5%), treated with either high doses of ICS or ICS and long-acting beta2-agonist, were considered as having severe asthma. Cough was reported after each inhalation of corticosteroids in 216 patients (53.7%). Among them, about 30% also complained of cough with beta2-agonists. Despite different propellants and dispersants, all corticosteroids induced cough similarly. Cough was not linked with asthma severity, but was significantly related to therapy duration and use of long-acting beta2-agonist. Type and volume of the spacer device, use of a face mask or mouthpiece were not influencing factors. Cough after inhalation of corticosteroids delivered from spacer devices is a frequent local side-effect in children with asthma. This side effect can greatly alter compliance. A practitioner must be sought at each visit.

PMID

14703724 [PubMed - indexed for MEDLINE]

Tipo di studio

Osservazionale

Livello di evidenza

3

Commento

La tosse può essere frequente durante l'inalazione con i corticosteroidi somministrati con il distanziatore e questo fattore può influenzare la compliance alla terapia

Titolo del documento

Nebuliser hood compared to mask in wheezy infants: aerosol therapy without tears ! 

Autori e Nazionalità

Amirav I, Balanov I, Gorenberg M, Groshar D, Luder AS. Israele

Fonte bibliografica

Arch Dis Child 2003;88:719-723

Lingua

Inglese

Abstract

BACKGROUND: Small volume nebulisers (SVNs) with masks commonly provide aerosol therapy for infants with lung diseases. However, infants and toddlers are often disturbed by and thus reject masks. AIMS: To compare the lung deposition efficiency of the "usual" SVN aerosol mask and a prototype hood attached to an SVN. The advantage of the hood is that no mask is needed and medication can readily be administered during sleep. METHODS: 99mTc salbutamol solution was administered at random by SVN plus mask or hood to 14 wheezy infants (mean age 8 (SD 5) months). The dose and distribution of salbutamol were evaluated using gamma scintigraphy. Clinical response, tolerability by the infants, and parent preference were also compared. RESULTS: Mean total lung deposition was 2.6% with the hood and 2.4% with the mask (p > 0.05). Variability with the mask was greater than with the hood (coefficient of variation (CoV) 54% v 39%). Both treatments provided similar clinical benefit and side effects as reflected in improved oxygen saturation, reduced respiratory frequency, and increased heart rate. Infants accepted the hood better than the mask and there was a positive correlation between poor acceptance and upper airways and stomach deposition for both treatment modalities. Parents preferred the hood treatments. CONCLUSIONS: Aerosol therapy by hood is as efficient as by mask but provides a better therapeutic index. It is much better tolerated by infants and preferred by parents. Hood nebulisation is a simple and patient friendly mode of aerosol therapy in wheezy infants.

PMID

12876173 [PubMed - indexed for MEDLINE]

Tipo di studio

Randomizzato in aperto, cross over 

Livello di evidenza

1-

Commento

L'autore propone il trattamento aerosolico con salbutamolo effettuato attraverso una cappa (del tipo di quella usata nell'ossigenoterapia dei neonati): in questo modo si eviterebbe il pianto e gli effetti clinici sarebbero gli stessi. Il numero di pazienti arruolati è molto esiguo (n =14). Possibili i bias.

Titolo del documento

Funhaler spacer:improving adherence without compromising delivery

Autori e Nazionalità

Watt PM, Clements B, Devadason SG, Chaney GM. Australia 

Fonte bibliografica

Arch Dis Child 2003;88:579-581 

Lingua

Inglese

Abstract

A novel asthma spacer device, the "Funhaler", incorporates incentive toys which are isolated from the main inspiratory circuit by a valve. Here we show that its use does not compromise drug delivery. Improved adherence combined with satisfactory delivery characteristics suggest that the Funhaler may be useful for management of young asthmatics

PMID

12818901 [PubMed - indexed for MEDLINE]

Tipo di studio

Osservazionale

Livello di evidenza

3

Commento

L'output aerosolico dopo erogazione di beclometasone e di salbutamolo spray con il nuovo distanziatore Funhaler non è diverso di quello che si ottiene con un distanziatore di controllo. Il Funhaler è associato con un miglior grado di aderenza

Titolo del documento

Demonstrated use of metered-dose inhalers and peak flow meters by children and adolescents with acute asthma exacerbations

Autori e Nazionalità

Scarfone RJ, Capraro GA, Zorc JJ, Zhao H. USA

Fonte bibliografica

Arch Pediatr Adolesc Med 2002;156:378-383

Lingua

Inglese

Abstract

OBJECTIVES: To determine the ability of children and adolescents with acute asthma exacerbations to adhere to national guidelines for proper metered-dose inhaler (MDI) and peak flow meter (PFM) technique and to define characteristics associated with improper use. DESIGN: A prospective study in which the patients were instructed to use a placebo MDI or a PFM in the emergency department exactly as at home. Technique was graded on the basis of performance of specific steps recommended by national guidelines. SETTING AND PARTICIPANTS: Children and adolescents (aged 2-18 years) with acute asthma exacerbations in the emergency department of an urban children's hospital with acute asthma. RESULTS: Thirty-three (45.2%) of 73 patients using an MDI (MDI group) demonstrated multiple steps improperly compared with 60 (44.4%) of 135 using an MDI with a holding chamber (MDI-HC group; P =.92). In the MDI group, young ages of the patients (P<.008) and the parents (P<.003) were associated with improper use. In the MDI-HC group, factors independently and significantly associated with improper use were no hospitalizations within the past year, parent assistance of the patient with MDI-HC use, and nondaily use of the MDI-HC. Also, 165 (82.9%) of 199 children who, per national guidelines, should be using a PFM at home, did not. Eighty-two (73.9%) of 111 patients demonstrated perfect performance of all PFM steps. CONCLUSIONS: Among children with acute asthma, we found high rates of improper MDI use and PFM underuse. A greater emphasis must be placed on teaching methods to optimize drug delivery and to instruct patients about the importance of self-monitoring of disease severity.

PMID

PMID: 11929373 [PubMed - indexed for MEDLINE]

Tipo di studio

Osservazionale

Livello di evidenza

2+

Commento

Tra i bambini che arrivano al PS per asma acuto (e che usano abitualmente lo spacer) è elevata la percentuale di coloro che utilizzano in modo improprio lo spray con il distanziatore: solo il 24% non compie alcun errore... 

Titolo del documento

Adrenal suppression in asthmatic children receiving low-dose inhaled budesonide: comparison between dry powder inhaler and pressurized metered-dose inhaler attached to a spacer.

Autori e Nazionalità

Goldberg S, Einot T, Algur N, Schwartz S, Greenberg AC, Picard E, Virgilis D, Kerem E. Israele

Fonte bibliografica

Ann Asthma Allergy Immunol 2002;89:566-571.

Lingua

Inglese

Abstract

BACKGROUND: Dry powder inhalers (DPI) have in recent years become a common mode for administration of inhaled corticosteroids for preventive therapy of asthma. Inhaled steroids delivered by DPI achieve increased lung deposition compared with pressurized metered-dose inhalers (pMDI), which is associated with increased therapeutic effect. This may be associated with increased systemic absorption. OBJECTIVE: The purpose of this study was to evaluate the prevalence of adrenal suppression in children using low-dose budesonide given by DPI, as compared with pMDI attached to a large-volume spacer device (pMDI + spacer). METHODS: In an open-labeled crossover study, 15 asthmatic children aged 5 to 15 years received 200 microg of inhaled budesonide twice daily by DPI (Turbuhaler, Astra, Draco AB, Lund, Sweden) and by pMDI + spacer, 1 month each, in a randomized order. Twenty-four-hour urine collections were performed at baseline and at the end of each of the 2 months of the study period, and urinary cortisol and creatinine were measured. RESULTS: Baseline urinary cortisol:creatinine was 0.038 +/- 0.012 microg/mg, similar in both groups. After 1 month of DPI therapy, urinary cortisol:creatinine was reduced by 27 +/- 16% to 0.028 +/- 0.012 microg/mg (P = 0.018). Urinary cortisol:creatinine after 1 month of pMDI + spacer therapy was similar to baseline 0.037 +/- 0.019 microg/mg (P = 0.78). CONCLUSIONS: Treatment of asthmatic children with budesonide 400 microg daily given via a DPI for 1 month was associated with hypothalamic-pituitary-adrenal axis suppression. This effect was not observed with the same dose of budesonide administered via pMDI + spacer. This indicates that systemic absorption might be reduced with pMDI + spacer therapy.

PMID

12487221 [PubMed - indexed for MEDLINE]

Tipo di studio

Osservazionale

Livello di evidenza

3

Commento

Il trattamento per un mese con budesonide 400 ugr die in 15 asmatici di età 5-15 anni è associata con una soppressione dell'asse ipotalamo ipofisario, misurata tramite il dosaggio del cortisolo libero urinario. Un tale comportamento non si osserva con l'utilizzo dello stesso farmaco somministrato con lo spray con il distanziatore. E' stato arruolato in questo studio cross sectional uno scarso numero di partecipanti.

Titolo del documento

A 500- ml plastic bottle: an effective spacer for children with asthma

Autori e Nazionalità

Zar HJ, Asmus MJ, Weinberg EG. Sud Africa

Fonte bibliografica

Pediatr Allergy Immnuol 2002;13:217-222

Lingua

Inglese

Abstract

Inhaled therapy using a metered-dose inhaler (MDI) with attached spacer has been increasingly recognized as the optimal method for delivering asthma medication for acute attacks and chronic prophylaxis. However, in developing countries the cost and availability of commercially produced spacers limit the use of MDI-spacer delivery systems. A 500-ml plastic bottle has been recently adapted to function as a spacer. This article reviews the current data on the efficacy of this bottle-spacer and discusses its advantages and limitations. It is concluded that a modified 500-ml plastic bottle is an effective spacer; modification and use of this device should be incorporated into international guidelines for the management of children with asthma.

PMID

12144645 [PubMed - indexed for MEDLINE]

Tipo di studio

Osservazionale

Livello di evidenza

3

Commento

Ecco come Zar ha preparato il suo distanziatore "fatto in casa": ha preso una bottiglia di plastica da 500 ml delle bibite, poi alla base ha applicato per 10 secondi un marchio di metallo incandescente che aveva la forma del beccuccio dello spray. Lo spray di plastica veniva applicato subito, mentre la base della bottiglia era ancora calda in modo da creare una stretta adesione. In questo modo lo spray rimaneva sigillato dentro la plastica. Nei bambini di età < 3 anni veniva inserita nella parte anteriore una mascherina di plastica

Titolo del documento

Drug delivery

Autori e Nazionalità

Le Souef. Australia 

Fonte bibliografica

Med J Aus 2002;177 Suppl:S69-S71 

Lingua

Inglese

Abstract

What we know: In preschool children, small-volume spacers perform better than large-volume spacers. Detergent is the best antistatic agent for spacers, increasing lung delivery two- to threefold, but it must not be rinsed off. A mouthpiece should be used in children aged 2-3 years or older, as lung delivery is two- to threefold higher for oral inhalation than nasal inhalation (ie, by mask). Inhaled drug doses do not generally need to be reduced in infants and young children owing to inefficiencies of delivery in younger patients. Nebulisers are "dinosaurs" and not needed for most children with asthma. What we need to know: What is the best inhalation technique for spacers? How long should children breathe, how many breaths should they take, and at what age should they breath-hold? How should children, parents and doctors be instructed to achieve optimal levels of electrostatic charge reduction for spacers? How much should inhaled steroid dose be reduced when a spacer is used optimally? What dosing instructions should be given for beta(2)-agonists delivered by spacer?

PMID

12225266 [PubMed - indexed for MEDLINE]

Tipo di studio

Revisione narrativa

Livello di evidenza

4

Commento

Risposte a domande di importanza pratica sull'uso dei distanziatori

testo

Titolo del documento

Child and parent satisfaction with the use of spacer devices in acute asthma

Autori e Nazionalità

Cotterell EM, Gazarian M, Henry RL, O'Meara MW, Wales SR. Australia

Fonte bibliografica

J Paediatr Child Health 2002,38:604-607.

Lingua

Inglese

Abstract

OBJECTIVE: To evaluate child and parent satisfaction with the use of spacers in acute asthma. METHODS: All parents of children presenting to the emergency department of Sydney Children's Hospital over a 3-month period with mild to moderately severe acute asthma who were treated with bronchodilators by spacer device were asked to complete an anonymous questionnaire. Children aged 8 years and older completed a separate questionnaire independently. RESULTS: One hundred and eleven of 158 parents (70%) responded. The majority (84%) found it 'easy' or 'very easy' to use the spacer and 85% reported that they intended to use the spacer at home. Of those parents who had previously used a nebulizer (n = 73), 84% said that the spacer was easier to use, 77% said that the spacer was better tolerated by their child and 84% said that overall they preferred the spacer. Seventeen of 31 children aged 8-14 years treated with a spacer (55%) responded to the satisfaction survey. All respondents found it 'easy' or 'OK' to use the spacer and the majority (82%) 'liked it' or thought 'it was OK'. The majority of children (82%) said that they preferred using spacers because it was quicker (29%) or easier to use (53%). CONCLUSION: The use of spacer devices in mild to moderately severe acute asthma is highly acceptable for children and parents; the majority prefer this mode of drug delivery to nebulization.

PMID

12410876 [PubMed - indexed for MEDLINE]

Tipo di studio

Inchiesta tramite questionario

Livello di evidenza

3

Commento

i bambini preferiscono lo spray con il distanziatore al nebulizzatore per somministrare i broncodilatatori nell'attacco acuto d'asma

Titolo del documento

An exploration of the skilss needed for inhalation therapy in schoolchildren wit asthma in Taiwan 

Autori e Nazionalità

Chen SH, Yin TJ, Huang JL. Taiwan

Fonte bibliografica 

Ann Allergy Asthma Immunol 2002;89(3):311-315

Lingua

Inglese

Abstract

BACKGROUND: Clinical observation has shown that many asthma-affected children and their parents are not familiar with appropriate techniques for inhaler use. This may result in misuse, overdose, or diminished response of the administered therapeutic drugs, or may even result in unnecessary, repeated hospitalization. Inappropriate inhalation technique is hazardous to the safety of children with asthma and unnecessarily increases costs resulting from unnecessary rehospitalization. OBJECTIVE: We designed a study to evaluate the skills needed for inhaler use among children with asthma in Taiwan. SUBJECTS AND METHODS: Schoolchildren with asthma, aged 8 to 13 years, were asked to demonstrate their inhalation technique. The inhalers used in this study were either metered-dose inhalers or dry-power inhalers. Assessment of the inhalation technique was made using a standardized inhaler checklist. A higher score indicates greater skill using the inhaler. RESULTS: This study surveyed 132 schoolchildren with asthma. Of those, only 23 (17.4%) asthmatic children who received inhalation therapy revealed good compliance with their medication regimens. No child was observed to have completed all inhaler techniques correctly. Those family members who participated in educational programs and who received instruction from health teams had higher scores for the inhaler checklist (P < 0.05). It was found that children who inhaled medication unaided had a better knowledge of asthma, and their drug inhalation technique was also more skillful (P < 0.03). By multiple regression analysis, we found that determinants of a child's skill at performing the inhalation maneuver included: number of asthma attacks within the preceding year, unaided application of inhaler therapy, older subject age, potential for subjects to receive instructions from parents regarding inhaler use, subjects reading related publications, and the family's degree of satisfaction with the physician's educational program. These variables contributed a total of 23% to variance in the subjects' inhalation technique. CONCLUSION: This study revealed that most asthmatic children being treated with inhaler medication do not use such devices appropriately. More aggressive asthma education is necessary in Taiwan.

PMID

12269653 [PubMed - indexed for MEDLINE]

Tipo di studio

Osservazionale

Livello di evidenza

3

Commento

La maggior parte dei bambini trattati con terapia inalatoria non dimostra una tecnica appropriata. A Taiwan sono pertanto necessari programmi educazionali più aggressivi

Titolo del documento

Spacer compliance after discharge following a mild to moderate asthma attack

Autori e Nazionalità

Cheng NG, Browne GJ, Lam LT, Yeoh R, Oomens M. Australia

Fonte bibliografica

Arch Dis Child 2002;87:302-305

Lingua

Inglese

Abstract

AIM: To assess MDIS usage in patients discharged from a children's hospital emergency department following a mild to moderate asthma attack. METHODS: Prospective observational study of 73 consecutive patients presenting to a children's hospital emergency department with a mild to moderate asthma attack. Demographic data, whether asthma literature/written MDIS instructions were provided, and who provided MDIS instructions (either a discharge coordinator or other emergency department staff) were noted. Parents of patients were telephoned after the first week following discharge and questioned about patient improvement, MDIS use/reasons for not using MDIS, and unscheduled presentations to their local doctor or hospital. RESULTS: Following discharge, 50/73 (68.5%) patients used MDIS exclusively (compliers), while 23/73 used nebulisers some or all of the time (non-compliers). There was no difference in patient improvement or unscheduled presentations between compliers and non-compliers. Most non-compliers 14/23 (60.9%) changed because of parental preference; ease of nocturnal nebuliser use was a possible factor. Compliance was associated with the age of the patient, spacer usage at hospital, the size of device used at hospital, and whether an information fact sheet was given. CONCLUSIONS: Most children discharged from the emergency department following a mild to moderate asthma attack continue MDIS use exclusively in the first week. MDIS compliance may be associated with knowledge, experience, and ease of spacer usage. The study shows that education for parents is crucial for MDIS compliance.

 

PMID

12244002 [PubMed - indexed for MEDLINE]

Tipo di studio

Osservazionale

Livello di evidenza

2+

Commento

L'educazione per il paziente è cruciale:dimessi dal Pronto Soccorso la maggior parte dei bambini con attacco d'asma lieve-moderato continuano ad utilizzare lo spray con il distanziatore per non più di una settimana

Titolo del documento

Dosage regimens for inhaled therapy in children should be reconsidered 

Autori e Nazionalità

Wildhaber JH, Monkhoff M, Sennhauser FH. Svizzera 

Fonte bibliografica

J Paediatr Child Health 2002;38:115-116

Lingua

Inglese

Abstract

In current asthma guidelines, dosage regimens for inhalation therapy in children are based on adult doses and are generally titrated per kilogram of bodyweight or per square metre of body surface area. However, these recommendations do not correspond well with current knowledge of aerosol therapy in childhood. Lung deposition of the aerosolised drug is the key determinant for clinical efficacy and for systemic side effects of inhalation therapy. Lung deposition increases with age, whereas lung deposition expressed as a percentage per kilogram bodyweight is age-independent. This finding is explained by the self-regulating effect of age-dependent airway anatomy on lung deposition. Therefore, it is more likely that adult doses translate into paediatric doses only by virtue of the differences in self-limiting pulmonary deposition when using the same absolute nominal doses of the medication. Adapting the adult dose to a paediatric dose calculated on body size might be unnecessary and could lead to insufficient pulmonary deposition of medication. These findings suggest that dosage regimens for inhalation therapy for children may have to be reconsidered, and should be determined from dose-ranging studies rather than calculated from adult doses based on body size.

PMID

12030988 [PubMed - indexed for MEDLINE]

Tipo di studio

narrativo

Livello di evidenza

4

Commento

La deposizione polmonare aumenta e quella orofaringea diminuisce con l'età a causa dell'anatomia delle vie aeree: in conseguenza i dosaggi dei farmaci somministrati come aerosol non dovrebbero essere espressi pro/kg, ma andrebbero riconsiderati sulla base di queste considerazioni.

Titolo del documento

Determinants  of correct inhalation technique in children attending an hospital-based asthma clinic.

Autori e Nazionalità

Kamps Aw, Brand PL, Roorda RJ. Olanda 

Fonte bibliografica

Acta Paediatr 2002;1:159-62.

Lingua

Inglese

Abstract

Many children with asthma use their inhaler device incorrectly even after comprehensive inhalation instruction. The aim of this study was to identify factors associated with correct inhalation technique. Two hundred children with asthma demonstrated their inhalation technique. Patient characteristics and the components of inhalation instructions they had received were compared for children demonstrating a correct or incorrect inhalation technique. In addition, the inhalation technique of 47 newly referred patients was followed-up prospectively after repeated comprehensive instruction sessions. Seventy-eight percent of all patients demonstrated a correct inhalation technique. Patients who had received repeated instruction sessions and patients who had previously been asked to demonstrate the use of their inhaler during an instruction session were more likely than other children to demonstrate a correct inhalation technique (p < 0.001 and p = 0.03, respectively). Multiple logistic regression analysis showed that repetition of instructions was significantly associated with a correct inhalation technique (odds ratio (OR) 8.2, 95% CI 3.2-21.5; p < 0.0001) irrespective of type of inhaler used. Demonstration of the inhaler use by the patient was significantly associated with a correct inhalation technique for patients using a metered dose inhaler plus spacer device (OR 3.5, 95% CI 1.0-12.6; p = 0.05). but not for patients using a dry powder inhaler (OR 1.6, 95% CI 0.4-6.4; p = 0.54). The number of newly referred patients demonstrating a correct inhalation technique improved from 57.4% to 97.9% after three comprehensive instruction sessions. CONCLUSION: Inhalation instruction should be given repeatedly to achieve and maintain correct inhalation technique in asthmatic children.

PMID

11952002 [PubMed - indexed for MEDLINE]

Tipo di studio

Osservazionale

Livello di evidenza

2+

Commento

Quei bambini che  sono stati controllati con ripetute sessioni educazionali sull'uso corretto dei distanziatori sono quelli che compiono poi meno errori

Titolo del documento

Factors affecting the efficiency of aerosol therapy with pressurised metered-dose inhalers through plastic spacers

Autori e Nazionalità

Chuffart AA, Sennhauser FH, Wildhaber JH. Svizzera

Fonte bibliografica

Swiaa Med Wkly 2001;131:14-18

Lingua

Inglese

Abstract

AIM: The main objective of this study was to compare the in vitro delivery of salbutamol from a chlorofluorocarbon(CFC)-propelled pressurised metered-dose inhaler (pMDI) versus a newly developed hydrofluoroalkane(HFA)-propelled pMDI through various spacers. In addition, we aimed to study the effect on bronchodilator response when using an optimal pMDI/spacer combination for aerosol delivery compared to a suboptimal combination. METHODS: Particle size distribution and output from salbutamol pMDIs containing either CFC propellants (Ventolin) or HFA propellants (Airomir) were measured using a multistage liquid impinger (MSLI) and compared to that through both detergent-coated (non-static) or untreated (static) large volume (Nebuhaler, Volumatic) and small volume (Aerochamber) plastic spacers. Flow-volume curves (FEV1) were obtained from twelve asthmatic children with known significant bronchodilator response (8 males), aged 13-17 years, randomly inhaling salbutamol from a CFC-pMDI through a static spacer (Nebuhaler) and from an HFA-pMDI through a non-static spacer (Nebuhaler). RESULTS: In vitro output of particles in the respirable range (< 6.8 microns) from HFA-pMDIs was significantly higher than that from CFC-pMDIs using various spacers. Removal of electrostatic charge increased output from CFC- and HFA-pMDIs through all spacers by 17-82%. The mean (SD) bronchodilator response after inhalation of salbutamol from a CFC-pMDI through a static spacer was 7.1% (6.3%) compared to 17.5% (7.9%) after inhalation from an HFA-pMDI through a non-static spacer (p = 0.002). CONCLUSIONS: Use of a newly developed HFA-propelled pMDI greatly improves drug delivery through spacers compared to a CFC-propelled pMDI. However, electrostatic charge in plastic spacers remains the key determinant limiting delivery of salbutamol from a pMDI through spacers, and can be reduced by soaking the spacer in a household detergent. Using an optimal pMDI/spacer combination leads to a significantly improved bronchodilator response.

PMID

11205181 [PubMed - indexed for MEDLINE]

Tipo di studio

Osservazionale

Livello di evidenza

3

Commento

Eseguire un lavaggio con detergente è fondamentale per ridurre le cariche elettrostatiche dei distanziatori non conduttori fatti di plastica. Gli autori suggeriscono come questo procedimento dovrebbe essere eseguito 1 volta alla settimana

Titolo del documento

Aerosol therapy with valved holding chambers in young childre: importance of the facemask seal 

Autori e Nazionalità

Amirav I, Newhouse MT. Israele 

Fonte bibliografica

Pediatrics 2001;108:389-394 

Lingua

Abstract

OBJECTIVE: Masks are an essential interface between valved holding chambers (VHCs), or spacers, and a small child's face for providing aerosol therapy. Clinical experience suggests that many young children do not cooperate with the VHC treatment or tolerate a mask of any kind. This might impair the mask-face seal and reduce the dose delivered to the child. The objective of this study was to evaluate the ability of parents to provide a good mask-face seal in infants and toddlers using 3 masks provided with commonly used pediatric VHCs and compare this with the seal obtained with the Hans Rudolph pediatric anesthesia mask. METHODS: A preliminary in vitro filter study was conducted to validate the assumption that reduced ventilation as a result of increased facemask leak reduces the drug aerosol dose delivered to the mouth. Facemask leak then was studied in vivo for NebuChamber, AeroChamber, BabyHaler, and Hans Rudolph masks by measuring ventilation with an in-line pneumotachograph while the facemask was held in place by experienced parents who were asked to demonstrate how they deliver medication to their children without any additional instruction. Thirty children (mean age: 3.2 +/- 1.4 years) performed 4 repeat studies with each mask. The first 10 patients performed the tests once again within 1 month. On the second occasion, the parents were coached continuously and encouraged to hold the mask tightly against the child's face. RESULTS: The AeroChamber and Hans Rudolph masks provided the best seal as reflected in the magnitude of the ventilation measured through them. The NebuChamber provided the poorest seal, with 45% less ventilation than the AeroChamber and Hans Rudolph masks. There was considerable intraindividual variability for all masks (24% to 48%); however, the variability with the NebuChamber mask was 2-fold greater than the other masks. All ventilatory volumes during the coached session were significantly greater than during the uncoached session. Variability during the coached session was significantly less (except for the BabyHaler, which remained unchanged). CONCLUSIONS: VHCs with masks designed for use with small children may provide a poor seal with the face, leading to reduced or more variable dose delivery. The facemask seal is critical for efficient aerosol delivery to infants and young children, and this should be stressed to parents.

PMID

11483804 [PubMed - indexed for MEDLINE

Tipo di studio

Osservazionale,  eseguito in laboratorio

Livello di evidenza

3

Commento

il grado di adesione della maschera facciale al viso è critico ai fini della quantità della dose inalata e della sua variabilità

Titolo del documento

Successful implementation of spacer treatment guideline for acute asthma.

Autori e Nazionalità

Powell CVE, Maskell GR, Marks MK, South M, Robertson CF. Australia

Fonte bibliografica

Arch Dis Child 2001;84:142-146

Lingua

Inglese

Abstract

AIMS: To develop and implement an evidence based guideline for the treatment of acute asthma using a metered dose inhaler and spacer combination. METHODS: Defined strategies were used for the development and implementation of a guideline, assessed by a prospective, descriptive, study using notes review, and patient, nursing, and medical staff telephone contact. The setting was a tertiary referral hospital in Victoria, Australia with 25 000 yearly admissions, and asthma accounting for about 7% of total. The first 200 children and families to use the guideline after its introduction were evaluated. RESULTS: A total of 191 (95.5%) children were treated according to the guideline. Six (3.0%) children were given nebulisers appropriately based on severity; five (2.5%) were given nebulisers at parental or child choice; and four (2.0 %) who did not have severe asthma, received nebulised treatment inappropriately. CONCLUSIONS: Successful implementation of a new evidence based guideline can be achieved using specific strategies for promoting the application of research findings in the clinical arena.

PMID

11159290 [PubMed - indexed for MEDLINE]

Tipo di studio

Osservazionale

Livello di evidenza

3

Commento

Come riuscire a trasformare lo spray con il distanziatore la metodica preferita per somministrare i broncodilatatori nell'attacco acuto d'asma in un grande ospedale pediatrico australiano

Titolo del documento

Inhalation treatment: errors in application and difficulties in acceptance of the devices are frequent in wheezy infants and young children

Autori e Nazionalità

Marguet C, Couderc L, Le Roux P, Jeannot E, Lefay V, Mallet E. Francia

Fonte bibliografica

Pediatr Allergy Immunol 2001;12;224-230

Lingua

Inglese

Abstract

The recent availability of small-volume spacers has facilitated the general use of inhaled treatment in infants. The purpose of this study was to evaluate any errors made by parents when using this new inhalation technique and the child's behavior during the inhalation. Ninety-four young children (61% boys) under 5 years of age were enrolled in the study. Inhalation treatment was recommended either by a general practitioner or by a pediatrician. Data concerning treatment regimens, the ability of parents to use the spacer and metered-dose inhalers (MDIs), and the acceptance of the devices, were collected by means of a demonstration and questionnaire. Unexpectedly, the doses, administration times, and duration of the treatments varied from one child to the next. No explanation or training in administering the treatment via the spacers was given to 12% and 47% of the parents, respectively. Fourteen per cent of parents did not shake the MDIs, 12% did not monitor the valves, and 22% allowed too short a time for inhalation. The lack of explanation increased the occurrence of errors in manipulation of the devices. The procedure was judged to be easy to follow by 78% of the parents, but the face mask was accepted with difficulty by 22% of the children. Repeated crying during administration of the treatment was observed in 38% of the patients, particularly the youngest. Crying influenced the acceptance of the face mask, reduced parental compliance, and made the use of the devices more difficult. Errors altering the efficiency of inhalation treatment in infants are frequent. Most of these errors could be avoided by spending more time to inform the parents about correct usage. Furthermore, repeated crying during inhalation is common in young children and this problem should to be taken into consideration in the evaluation of treatment.

PMID

11555320 [PubMed - indexed for MEDLINE]

Tipo di studio

Osservazionale

Livello di evidenza

3

Commento

Nei bambini piccoli, al di sotto dei 5 anni di età, che utilizzano il distanziatore gli errori di tecnica inalatoria sono comuni. Più di 1/3 piange durante la procedura

Titolo del documento

Metered-dose inhaler: the Emergency Department Orphan

Autori e Nazionalità

Tien I, Dorfman D, Kastner B, Bauchner H. USA

Fonte bibliografica

Arch Pediatr Adolesc Med 2001;155:1335-1339 

Lingua

Inglese

Abstract

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

PMID

11732952 [PubMed - indexed for MEDLINE]

Tipo di studio

Osservazionale

Livello di evidenza

3

Commento

Lo spray con il distanziatore:..... l'orfano dei Pronto Soccorso

Titolo del documento

Spacers and holding chambers: not the last word, we hope.

Autori e Nazionalità

Mitchell JP. Canada

Fonte bibliografica

Arch Dis Child 2001;84:89

Lingua

Inglese

Abstract

L'autore di questa lettera è direttore scientifico di un laboratorio di ricerca per aerosol: risponde a Zar che in un precedente articolo aveva dimostrato che un distanziatore di plastica fatto in casa derivato da una bottiglia delle bibite e senza valvole poteva essere utilizzato con la stessa efficacia di uno spacer commerciale dotato di valvole per somministrare i broncodilatatori nell'attacco acuto d'asma: Mitchell sostiene l'utilità delle valvole: perchè si evita la ri-immissione di aria nel distanziatore e perchè vengono trattenute le particelle più grossolane del farmaco, responsabili dell'impatto nelle alte vie respiratorie e nel cavo orale 

PMID

Tipo di studio

Opinione di esperto

Livello di evidenza

4  

Commento

Titolo del documento

Randomised controlled study of clinical efficacy of spacer therapy in asthma with regard to electrostatic charge

Autori e Nazionalità

Dompeling E, Oudesluys-Murphy AM, Janssens HM, Hop W, Brinkman JG. Olanda 

Fonte bibliografica

Arch Dis Child 2001;84:178-182

Lingua

Inglese

Abstract

BACKGROUND: Inhalation therapy using a pressured metered dose inhaler (pMDI) and a spacer is frequently used in the treatment of airway disease in children. Several laboratory studies found a clear negative influence of electrostatic charge (ESC) on plastic spacers on the delivery of aerosol. AIMS: To investigate whether ESC on plastic spacers could diminish bronchodilating responses to salbutamol. METHODS: Ninety asthmatic children (aged 4-8 years) were randomised into three groups: metal Nebuchamber, plastic Volumatic, and plastic Aerochamber. The bronchodilating response was measured by the change in peak expiratory flow rate (PEF) after 100 microgram and 400 microgram salbutamol. Within the Volumatic and Aerochamber groups, a crossover comparison was made between electrostatic and non-electrostatic spacers. RESULTS: We found no significant effect of ESC on the bronchodilating response to salbutamol with any of the doses in the Aerochamber and Volumatic groups. For the plastic spacers, the mean difference of the change in PEF after 100 microgram salbutamol between non-electrostatic and electrostatic spacers was only +1.7% (95% CI -1.3% to 4.7%). After 400 microgram salbutamol this was +1.9% (95% CI -1.4% to 5.1%). A comparable efficacy was found for the Nebuchamber, the Aerochamber, and Volumatic with respect to the change in PEF after 100 and 400 microgram salbutamol. CONCLUSION: This study showed no negative influence of ESC on plastic spacers with regard to clinical efficacy of a beta(2) agonist (salbutamol) in children with asthma. The metal Nebuchamber, plastic Aerochamber, and plastic Volumatic were equally effective.

PMID

11159302 [PubMed - indexed for MEDLINE]

Tipo di studio

Studio Clinico Randomizzato in aperto, cross over

Livello di evidenza

2 +

Commento

Titolo del documento

Aerosol delivery from spacers in wheezy infants : a daily life study 

Autori e Nazionalità

Janssens HM, Heljnen EM, de Jong VM, Hop WC, Holland WP, de Jongste JC, Tiddens HA . Olanda 

Fonte bibliografica

Eur Respir J 2000;1685).850-6.

Lingua

Inglese

Abstract

The aims of this study were to assess and compare dose delivery and dose variability of pressurized metered dose inhalers (pMDI)/spacers in wheezy infants in daily life and to investigate factors influencing aerosol delivery. In an open randomized crossover study in 25 wheezy infants aged 5-26 months, a metal spacer (Nebuchamber), a detergent coated (DC) and a non-detergent coated (nonDC) plastic spacer (Babyhaler) were tested at home for 7 days each. Budesonide (200 microg b.i.d) was administered via a Nebuchamber or fluticasone (125 microg b.i.d) via a Babyhaler. Aerosol was trapped in filters, positioned between the spacer and face mask. Cooperation was scored on diary cards. Electrostatic charge (ESC) of the spacers was measured. Evaluations of the administration technique were made from video recordings. Median (range) dose delivery of the filters expressed as per cent (%) of nominal dose, was 34% (3-59), 23% (1-49), and 41% (12-55) for the Nebuchamber, nonDC-Babyhaler, and DC-Babyhaler respectively. Considerable dose variability was found, median (range) within-subject dose variability, expressed as coefficient of variation, for the Nebuchamber (49% (15-249)) was significantly higher when compared with both nonDC- (36% (12-325)) and DC-Babyhalers (27% (10-122)), for which dose variabilities were similar. Detergent coating was effective to reduce electrostatic charge, and to increase dose delivery, but had no effect on dose variability. Bad cooperation was an important cause for high dose variability for all spacers (r=0.5-0.6, p<0.02). Many mistakes were made during the administration procedure.

PMID

11153582 [PubMed - indexed for MEDLINE

Tipo di studio

Randomizzato in aperto, di tipo cross over 

Livello di evidenza

2+

Commento

Il rivestimento con un detergente è efficace nel ridurre le cariche elettrostatiche, ma non ha effetto sulla variabilità della dose. Molti errori sono stati eseguiti durante l'inalazione

Titolo del documento

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

Autori e Nazionalità

Leversha AM, Campanella SG, Aickin RP, Asher MI 

Fonte bibliografica

J Pediatr 2000;136:497-502

Lingua

Inglese

Abstract

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.

PMID

10753248 [PubMed - indexed for MEDLINE]

Tipo di studio

Randomizzato

Livello di evidenza

2+

Commento

E' uno dei pochi SCR che confronta spacer vs nebulizzatori nell'attacco acuto d'asma, anche dal punto di vista della spesa: con i distanziatori si avrebbe una riduzione del 40% dei costi rispetto alla terapia tradizionale

Titolo del documento

Poor inhalation technique, even after inhalation instructions, in children with asthma.

Autori e Nazionalità

kamps AWA, van Ewicjk, Roorda RJ, Brand PLP. Olanda

Fonte bibliografica

Pediatr Pulmonol 2000;29:39-42

Lingua

Abstract

PMID

Tipo di studio

Livello di evidenza

Commento

Titolo del documento

Randomized trial of salbutamol via Metered-dose inhaler with spacer vesrus nebulizer for acute wheezing in children less than 2 years of age

Autori e Nazionalità

Fonte bibliografica

Lingua

Abstract

PMID

Tipo di studio

Livello di evidenza

Commento

Anche nei bambini piccoli di età < 2 anni con broncospasmo moderato grave somministare i beta2 agonisti tramite spray con il distanziatore dà un miglioramento dello score clinico più rapido che erogare gli stessi farmaci tramite nebulizzatore

Titolo del documento

Lung deposition of a aerosol-a comparison of different spacers

Autori e Nazionalità

Zar HJ, Weinberg EG, Binns HJ, Gallie F, Mann MD. Sud Africa 

Fonte bibliografica

Arch Dis Child 2000;82:495-498

Lingua

Inglese

Abstract

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.

PMID

10833188 [PubMed - indexed for MEDLINE]

Tipo di studio

sperimentale, di laboratorio

Livello di evidenza

Commento

Una bottiglia di plastica delle bibite, modificata una deposizione polmonare maggiore di un distanziatore convenzionale

Titolo del documento

Is nebulized aerosol treatment necessary in teh Pediatric Emergency Department ? 

Autori e Nazionalità

Mandelberg A, Tsehori S, Houri S, Gilad E, Morag B, Priel EI. Israele

Fonte bibliografica

Chest 2000;117:1309-1313

Lingua

Inglese

Abstract

BACKGROUND: Infants and small children admitted to the pediatric emergency department (PED) with acute wheezing episodes (AWE) are currently treated with nebulized wet aerosol (NWA). OBJECTIVE: To determine the efficacy of MDI with Nebuchamber (Astra AB; Lund, Sweden), a nonelectrostatic spacer device (NESD), as compared to NWA in the treatment of an unselected population of babies and small children with AWE. DESIGN: Randomized, double-blind, placebo-controlled trial. Forty-two children referred to the PED (median age +/- SD, 16 +/- 15 months) with AWE received either placebo MDI through a NESD (four puffs) and salbutamol 0.5 mL (2.5 mg) as a NWA (group I, n = 19), or salbutamol MDI and 0.5 mL of saline solution administered in the same manner as above (group II, n = 23). This treatment was repeated three times every 20 min. RESULTS: The respiratory rates (RRs) at baseline were as follows: group I, 45 +/- 11.2 breaths/min; and group II, 52.3 +/- 11.3 breaths/min (p = not significant [NS]). After the first, second, and third interventions, the percent fall from baseline of the RR were as follows: group I, 8.9, 13.1, and 17.9%, respectively; group II, 8. 6, 14.6, and 18.6%, respectively. There was no significant difference at any time in the results between the two groups. The clinical scores (CSs) at baseline were as follows: group I, 6.6 +/- 1.3; group II, 6.8 +/- 1.49 (p = NS). After the first, second, and third interventions, the percent fall from baseline of the CS were as follows: group I, 9.1, 17.9, and 23.2%, respectively; group II, 8. 6, 18.9, and 24.7%, respectively. These results, also, did not differ significantly at any time between the two groups. Hospitalization rate and side effects did not differ between the two groups. CONCLUSIONS: We conclude that even in the group of unselected very young children (mean age < 2 years) with AWE, the use of MDI with NESD is at least as effective as the use of NWA. As opposed to data from an adult population, no plateau was reached in the dose-response curve using the above doses over time.

PMID

10807815 [PubMed - indexed for MEDLINE]

Tipo di studio

Randomizzato in doppio cieco

Livello di efficacia

1+

Commento

Titolo del documento

High-dose albuterol by metered-dose inhaler plus a spacer device versus nebulization in preschool children with recurrent wheezing: a double-blind equivalence trial

Autori e Nazionalità

Ploin D, Chapuis FR, Stamm D, Robert J, David L, Chatelain PG, Dutau G, Floret D. 

Fonte bibliografica

Pediatrics 2000; 106;311-7.

Lingua

Inglese

Abstract

Inhaled albuterol is the most frequently used bronchodilator for acute wheezing, and nebulization is the standard mode of delivery in hospital setting. However, recent guidelines consider spacer devices as an easier to use, and cost-saving alternative and recommend the high-dose metered-dose inhaler bronchodilator. OBJECTIVE: To demonstrate clinical equivalence between a spacer device and a nebulizer for albuterol administration. DESIGN: Randomized, double-blind, parallel group equivalence trial. SETTING: Pediatric emergency wards at 2 tertiary teaching hospitals. PATIENTS: Sixty-four 12- to 60-month-old children with acute recurrent wheezing (32 per group). INTERVENTIONS: Albuterol was administered through the spacer device (50 microg/kg) or through the nebulizer (150 microg/kg) and repeated 3 times at 20-minute intervals. Parents completed a questionnaire. OUTCOME MEASURES: Pulmonary index, hospitalization, ease of use, acceptability, and pulse oximetry saturation. RESULTS: The 90% confidence interval of the difference between treatment groups for the median absolute changes in pulmonary index values between T0 and T60 was [-1; +1] and was included in the equivalence interval [-1.5; +1.5]. Clinical improvement increased with time. Less than 10% of the children (3 in each group) required hospitalization (2 in each group attributable to treatment failure). Parents considered administration of albuterol using the spacer device easier (94%) and better accepted by their children (62%). CONCLUSIONS: The efficacy of albuterol administered using the spacer device was equivalent to that of the nebulizer. Given its high tolerance, repeated 50-microg/kg doses of albuterol administered through the spacer device should be considered in hospital emergency departments as first-line therapy for wheezing.

PMID

10920157 [PubMed - indexed for MEDLINE]

Tipo di studio

Randomizzato in doppio cieco

Livello di evidenza

1+

Commento

Spray con il distanziatore vs nebulizzatore per somministrare i broncodilatatori nella terapia dell'attacco acuto d'asma.

Titolo del documento

Future options for aerosol delivery to children

Autori e Nazionalità

Bisgaard H. Danimarca

Fonte bibliografica

Allergy 1999;54 Suppl 49:97-103

Lingua

Inglese

Abstract

There is an increasing awareness of the importance of reliable aerosol delivery, with emphasis on the dose delivered to the lungs, optimal clinical control, cost-effectiveness, and safety in children. Dose prescription should relate to the expected lung dose rather than the factory-dispensed dose, as at present. The device determines the lung dose. Clearly, therefore, the device should be considered an integral part of the prescription. Drug approval processes should clearly specify the device, and discourage the use of other devices. This would rationalize the choice of devices. Important new insights into factors essential for drug delivery to the airways have been acquired in recent years. Nasal inhalation increases systemic bioavailability, reduces lung dose, and adds to its variability; hence, face masks to prevent nasal breathing have been developed. Similarly, dead space in the inspiratory line causes a proportional reduction in lung dose; hence, attention should be paid to reducing such dead space. Plastics in spacers cause a rapid loss of drug due to electrostatic attraction of the aerosol. The residence time of the aerosol, i.e., the time available for inhalation, is increased in nonelectrostatic spacers, allowing less compliant children enough time to obtain a full dose. Eliminating the electrostatic charge can change the lung dose by several times; hence, nonelectrostatic materials should be used in future spacer devices. Compliance is the biggest problem in drug delivery to children. The inhaler design process should be reversed, adapting technology to the child. Interactive microchip technology should provide intelligent devices that react to correct handling and breathing maneuvers. An intelligent nebulizer has been developed that adapts nebulization to the child's breathing pattern, nebulizing only during inhalation and avoiding loss of aerosol during exhalation. An automatic device (AirPac) has been developed that transforms a dry-powder inhaler, Turbuhaler, into a spacer. In addition to the general advantages of spacer treatment, this device offers the advantage of a drug aerosol delivered without use of propellants or additives. The mechanical actuation ensures highly repeatable drug delivery. Finally, a nonelectrostatic, tower-shaped spacer provides a stable aerosol, which remains airborne for a prolonged period. The spacer is equipped with a face mask that prevents nasal breathing. Such features should improve our ability to treat young children with inhaled drug aerosols.

PMID

10422756 [PubMed - indexed for MEDLINE]

Tipo di studio

Revisione narrativa

Livello di evidenza

4

Commento

L'autore passa in rassegna le nuove tecnologie adottate per favorire la deposizione aerosolica nel paziente. Un po' datato.

Titolo del documento

Washing plastic spacers in household detergent reduces electrostatic chrage and greatly improves delivery 

Autori e Nazionalità

Piérart F, Wilhaber JH, Vrancken I, devadason SG, Le Souef PN. Australia 

Fonte bibliografica

Eur respir J 1999;13:637-638

Lingua

Inglese

Abstract

Ionic detergents reduce electrostatic charge on plastic spacers, thereby improving in vitro drug delivery. The aim of this study was to gain practical information on the use of detergents and to evaluate the relevance of this information on in vivo drug deposition. Measurement of electrostatic charge and salbutamol particle size distribution was carried out on detergent-coated and noncoated plastic spacers. The efficiency of four household detergents was compared, and the influence of dilution and the duration of the antistatic effect were studied. In addition, the level of radiolabelled salbutamol deposition in the lungs of eight healthy adults was compared after inhalation through a new versus a detergent-coated spacer. In vitro, all tested detergents reduced the electrostatic charge on the spacer surface. This resulted in a mean increase of 37.4% (range 33.5-41.2) in small particle (<6.8 microm) salbutamol output compared with water-rinsed/drip-dried spacers. Dilution had no influence on the results and the effect lasted for at least four weeks. In vivo, the mean lung deposition of radiolabelled salbutamol in healthy subjects was 45.6% (range 43.4-49.5) through a detergent-coated spacer compared to 11.5% (range 7.6-17.9) through a static spacer (p<0.001). In conclusion, household detergents offer a simple and practical solution to the problem of static on plastic spacers and significantly improve both in vitro and in vivo delivery of salbutamol.

PMID

10232445 [PubMed - indexed for MEDLINE]

Tipo di studio

Osservazionale

Livello di evidenza

3

Commento

i detersivi casalinghi offrono una soluzione efficace e poco costosa per ridurre le cariche elettrostatiche dentro i distanziatori

Titolo del documento

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

Autori e Nazionalità

Duarte M, Camargos P. Brasile 

Fonte bibliografica

Acta Paediatr 2002;91:909-13.

Lingua

Inglese

Abstract

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.

PMID

12412864 [PubMed - indexed for MEDLINE]

Tipo di studio

Randomizzato

Livello di evidenza

1+

Commento

Spray con una bottiglia di plastica fatta in casa o ampolla attaccata alla presa di ossigeno per somministrare i broncodilatatori nell'attacco acuto d'asma.

Titolo del documento

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

Autori e Nazionalità

Schuh S, Johnson DW, Stephens D, Callahan S, Winders P, Canny GJ. Canada

Fonte bibliografica

J Pediatr 1999;135:22-27

Lingua

Inglese

Abstract

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.

PMID

10393599 [PubMed - indexed for MEDLINE]

Tipo di studio

Randomizzato, in doppio cieco

Livello di evidenza

1+

Commento

Uno dei tanti studi di confronto distanziatori versus nebulizzatori per somministare i broncodilatatori. Qui vengono confrontati due dosaggi di salbutamolo spray: 2 puff e 6-10 puff

Titolo del documento

Home-made spacers for bronchodialator therapy in children with acute asthma: a randomised trial

Autori e Nazionalità

Zar HJ, Brown G, Donson H, Brathwalte N, Mann MD, Weinberg EG. Sud Africa

Fonte bibliografica

Lancet 1999;354(9183):979-82 

Lingua

Inglese

Abstract

BACKGROUND: A metered-dose inhaler (MDI) with spacer is the best way to deliver bronchodilator therapy for treatment of acute asthma. In developing countries, commercially produced spacers are generally unavailable or too costly. We tested the efficacy of home-made spacers (500 mL plastic bottle, polystyrene cup) compared with a conventional spacer for delivery of a beta2 agonist via MDI for children with acute asthma. METHODS: We studied children aged 5 to 13 years with acute asthma, stratified into those with mild airways obstruction (peak expiratory flow [PEF] 60-79% of predicted value) or moderate to severe airways obstruction (PEF 20-59% of predicted value). A beta2 agonist (fenoterol hydrobromide) was given via MDI and one of four randomly assigned spacers (conventional spacer, sealed 500 mL plastic bottle, unsealed 500 mL bottle, 200 mL polystyrene cup). Clinical score, pulmonary function tests, and oximetry were recorded at baseline and 15 min after treatment. If a second bronchodilator treatment was needed, nebulised fenoterol was given and the assessment repeated 15 min later. Primary outcome measures were changes in clinical score and pulmonary function, and need for and response to nebulisation. FINDINGS: 88 children were eligible for study. In 44 children with moderate to severe airways obstruction, a cup gave significantly less bronchodilation (median increase in: forced expiratory volume in 1 s [FEV1] 0%; PEF 12%) compared with the conventional spacer (37%; 59%), sealed bottle (33%; 36%), or unsealed bottle (18%; 21%, p<0.05 for difference between groups). Nebulisation was required by ten of 11 who had used a cup, nine of 11 who had used an unsealed bottle, eight of 11 who had used a sealed bottle, and only four of 11 who had used a conventional spacer. After nebulisation, improvement in FEV1 (15.5%) and PEF (26%) was more marked in children who had used a cup than in those who had used a conventional spacer (5.5% FEV1; 4% PEF), sealed bottle (3%; 0%), or unsealed bottle (7%; 9%). For 44 children with mild airways obstruction, response to bronchodilator was similar for all spacers and need for nebulisation was not associated with use of a particular spacer. INTERPRETATION: A conventional spacer and sealed 500 mL plastic bottle produced similar bronchodilation, an unsealed bottle gave intermediate improvement in lung function, and a polystyrene cup was least effective as a spacer for children with moderate to severe airways obstruction. Use of bottle spacers should be incorporated into guidelines for asthma management in developing countries.

 

PMID

10501359 [PubMed - indexed for MEDLINE]

Tipo di studio

Randomizzato

Livello di evidenza

1+

Commento

Ilprimo SCR eseguito da Zar che dimostra l'uguaglianza di efficacia nel somministare i broncodilatatori con una bottiglia di plastica delle bibite o con un distanziatore del commercio nell'attacco acuto d'asma 

Titolo del documento

A randomised contolled trial to assess the relative benefits of large volume spacers and nebulisers to treat acute asthma in hospital

Autori e Nazionalità

Dewar AL, Stewart A, Cogswell JJ, Connett GJ. Gran Bretagna

Fonte bibliografica

Arch Dis Child 1999;80:421-23

Lingua

Inglese

Abstract

OBJECTIVES: To compare the clinical effectiveness, acceptability, and cost benefit of administering beta2 agonists by means of a metered dose inhaler and large volume spacer with conventional nebulisers to children admitted to hospital with acute asthma. METHODS: A randomised controlled trial was conducted over five months. Sixty one children older than 3 years admitted to a large teaching hospital and a district general hospital with acute asthma completed the study. Children received either 5 mg of salbutamol up to one hourly by jet nebuliser, or up to 10 puffs of salbutamol 100 microg by means of a metered dose inhaler and spacer up to one hourly. RESULTS: Median hospital stay was 40 hours in the nebuliser group and 36.5 hours in the spacer group. Asthma disability scores at two weeks after discharge were significantly improved in the spacer group. Drug costs were pound 14.62 less for each patient in the spacer group. CONCLUSIONS: Large volume spacers are an acceptable, cost effective alternative to nebulisers in treating children admitted with acute asthma, provided that the children can use the mouthpiece, and symptoms are not severe. Their use facilitates effective home treatment by parents, with subsequent reduction in morbidity and re-admission rates.

PMID

10208945 [PubMed - indexed for MEDLINE]

Tipo di studio

Randomizzato

Livello di evidenza

1+

Commento

Uno degli studi di confronto distanziatori vs nebulizzatori per somministrare i broncodilatatori nell'attacco acuto d'asma, incluso nella Revisione Sistematica della Cochrane di Cates

Titolo del documento

Structured discharge procedure for children admitted to hospital with acute asthma: a randomised controlled trial of nursing practice

Autori e Nazionalità

Wesseldine LJ, McCarthy P, Silverman M. Gran Bretagna

Fonte bibliografica

Arch Dis Child 1999;80:110-114

Lingua

Inglese

Abstract

BACKGROUND: Discharge planning is becoming an important part of the management of childhood asthma in hospital. Readmission to hospital, although often inevitable, might represent a failure of the opportunity for intervention presented by a brief period of supervised care in hospital. AIM: To examine the impact of a structured, nurse-led discharge package for children admitted to hospital with acute asthma on readmission to hospital, reattendance at the accident and emergency (A&E) department, and general practitioner consultations for asthma. METHODS: A structured nurse-led discharge package, consisting of a 20 minute patient education programme and self management plan for children with asthma was developed on the wards of a busy children's hospital. A randomised controlled trial was conducted involving 160 children aged 2-16 years admitted for asthma over a 12 month period. Readmission and A&E reattendance's over the six months after discharge from hospital were obtained from the hospital computerised information system and general practitioner consultations from practice records. RESULTS: Children in the intervention group were significantly less likely to be readmitted to hospital in the next six months than those in the control group (12 of 80 v 30 of 80 patients), and significantly less likely to attend the A&E department (6 of 80 v 31 of 80). Significantly fewer children in the intervention group had visits to their general practitioner for problematic asthma (31 of 78 v 72 of 77 for whom data were available). CONCLUSION: By delivering the simplest form of education and support during a child's stay in hospital, readmissions over a six month period were reduced. The programme was designed to be suitable for administration by nursing staff on the children's wards after a brief period of training.

 

PMID

10325723 [PubMed - indexed for MEDLINE]

Tipo di studio

Randomizzato

Livello di evidenza

2+

Commento

Un pacchetto educazionale fornito da un'infermiera della durata di 20' riduce la frequenza del ricovero per asma nei successivi 6 mesi.

Titolo del documento

Variability of aerosol delivery via spacer devices in young asthmatic children in daily life 

Autori e Nazionalità

Janssens HM, Devadason SG, Hop WC, Le Souef PN, de Jongste JC,Tiddens HA

Fonte bibliografica

Eur Respir J 1999;13(4):787-9

Lingua

Inglese

Abstract

Pressurized metered dose inhalers (pMDI) are widely used together with spacers for the treatment of asthma in children. However, the variability of daily medication dose for pMDI/spacer combinations is not known. Electrostatic charge is a potential source of dose variability. Metal spacers have no static charge. This study assessed and compared within-subject variability of aerosol delivery of metal and plastic spacers. This was a randomized, crossover study in children with stable asthma aged 1-4 (group I, n=17) and 5-8 (group II, n=16) yrs. In both groups the amount of drug delivered to the mouth by a metal spacer (Nebuchamber) and one of two plastic (polycarbonate) spacers, i.e. Babyhaler in group I and Volumatic in group II was measured. The metal and plastic spacers were tested at home in a randomized order for 7 days each, using budesonide (200 microg b.i.d.). Aerosol was collected on a filter positioned between spacer and facemask or mouth. Budesonide on the filter was assessed by high performance liquid chromatography. The mean filter dose for each child (mean+/-SD) during the 7 days was expressed as a percentage of the nominal dose. Within-subject variability was expressed as coefficient of variation (CV). Mean filter dose in group I was 41.7+/-10.1% for Nebuchamber and 26.0+/-4.0% for Babyhaler (p<0.001). Mean filter dose in group II was 50.2+/-9.2% for Nebuchamber and 19.4+/-7.2% for Volumatic (p<0.001). Mean CV in group I was 34% for Nebuchamber and 37% for Babyhaler (p=0.44). Mean CV in group II was 23% for Nebuchamber and 34% for Volumatic (p=0.003). There was substantial within-subject dose variability in aerosol delivery in children using a pMDI/spacer at home. This variability was lower for the metal than for the plastic spacer in children 5-8 yrs of age. The dose delivered to the mouth was about two-fold higher for the metal than the plastic spacer independent of age

PMID

10362041 [PubMed - indexed for MEDLINE]

Tipo di studio

Studio osservazionale eseguito in laboratorio

Livello di evidenza

2 +

Commento

La dose di budesonide, somministrata con lo spray nella Nebuchamber di metallo che arrivava alla bocca era 2 volte superiore a quella che era possibile ottenere con il Volumatic di plastica

Titolo del documento

Efficacy of bronchodilators administered by nebulizers versus spacer devices in infants with acute wheezing 

Autori e Nazionalità

Closa RM, Ceballos JM,Gomez-Papi A, Galiana AS, Gutierrez C, Marti-Henneber C. Spagna

Fonte bibliografica

Pediatr Pulmonol 1998;26:344-348

Lingua

Inglese

Abstract

The aim of this study was to compare the response of infants with acute wheezing to treatments with inhaled terbutaline when administered by nebulizer or by metered-dose inhaler and spacer device (MDI-spacer). Thirty-four infants between the ages of 1 and 24 months who were seen in our emergency department for acute wheezing were studied in a double-blind, randomized trial. The participants received two treatments of terbutaline at 20-min intervals, either by a nebulizer (2 mg/dose in 2.8 mL of 0.9% saline solution) or by an MDI-spacer device (0.5 mg/dose). The outcome measure was a clinical score, based on respiratory rate, degree of wheezing, retractions, degree of cyanosis, color, and pulse oximetry data measured before treatment, 20 min after the first treatment, and again 20 min after the second treatment. There was no difference in the rate of improvement in the clinical score between infants who received terbutaline by nebulizer and those who received it by MDI-spacer. We conclude that MDI-spacers and nebulizers are equally effective means of delivering beta-2 agonists to infants and small children with acute wheezing.

PMID

9859904 [PubMed - indexed for MEDLINE]

Tipo di studio

Randomizzato in doppio cieco

Livello di evidenza

1+

Commento

testo

Kenyon CJ, Thorsson L, Borgstrom L, Newman SP. Gran Bretagna 

Eur Respir J 1998;11:606-610.

Inglese

Electrostatic charge in plastic spacer devices has been shown in vitro to reduce delivery of asthma medications intended for inhalation, but the effect of static charge on in vivo drug deposition is unknown. A six-way randomized crossover study was conducted in 10 mild asthmatic patients. Two plastic spacers (Nebuhaler and Volumatic) and one metal spacer (Nebuchamber) were tested. The spacers were used either "primed" or "unprimed". Priming was performed by firing 20 doses of placebo aerosol into a new spacer, hence coating the inner surface with surfactant and minimizing static charge. Unprimed spacers were new and were not treated. Pressurized aerosol canisters delivering budesonide (200 microg Pulmicort) were radiolabelled with the radionuclide 99mTc and lung deposition was measured by gamma scintigraphy. The radiolabel was shown to be a valid marker for the drug substance prior to the clinical phase of the study. Priming significantly increased mean whole lung deposition following inhalation from plastic spacers (Nebuhaler primed 37.7% and unprimed 26.7%, p=0.01; Volumatic primed 32.0% and unprimed 22.1%, p=0.02). Priming had no effect on the mean whole lung deposition following inhalation from the Nebuchamber (primed 33.5% and unprimed 32.9%). Lung deposition in vivo from plastic spacer devices will vary according to the electrostatic charge on the spacer walls. Priming reduces retention of drug on plastic spacer devices and increases lung deposition. Metal spacers are not susceptible to static charge, which should result in more predictable lung deposition.

9596110 [PubMed - indexed for MEDLINE]

Osservazionale

3

Titolo del documento

Comparative efficacy of jet nebulizer and metered dose inhaler with spacer device in the treatment of acute asthma.

Autori e Nazionalità

Batra V, Sethi GR, Sachdev HP. India

Fonte bibliografica

Indian Pediatr 1997;34:497-503.

Lingua

Inglese

Abstract

OBJECTIVE: To compare the relative efficacy of jet nebulizer and metered dose inhaler (MDI) with spacer for the administration of aerosolized salbutamol in an acute exacerbation of bronchial asthma. DESIGN: Randomized prospective study. SETTING: Emergency Room. METHODS: In 60 subjects with acute asthma aged between 1 to 12 years, clinical and laboratory assessment of severity at recruitment included heart rate, respiratory rate, pulsus paradoxus, arterial blood gas analysis (all cases) and peak expiratory flow rate (wherever possible). The subjects were randomized into two equal groups to receive aerosolized salbutamol either via nebulizer (Group I) or MDI-spacer (Group II) as per the Consensus Guidelines. The response to therapy was sequentially assessed after 20, 40 and 60 minutes of institution of therapy. RESULTS: A significantly (p < 0.02) greater number of subjects in Group II presented with severe dyspnea and intercostal muscle retraction (subjective assessment). However, the objectively evaluable outcome parameters were comparable (p > 0.05) in both groups at presentation. All the outcome measures showed a significant (p < 0.05) improvement with time in both the groups. The recovery parameters were comparable (p > 0.05) at different time periods in the two groups. CONCLUSION: MDI-spacer is as effective as a nebulizer for the aerosolized administration of salbutamol in an acute exacerbation of asthma in children. However, for developing countries, distinct advantages (economic and power requirement) argue strongly for utilization of MDI-spacer in preference to nebulizer.

PMID

9357205 [PubMed - indexed for MEDLINE]

Tipo di studio

Randomizzato 

Livello di evidenza

1+

Commento

Incluso nella Revisione Sistematica della Cochrane di confronto distanziatori vs nebulizzatori per somministrare i broncodilatatori nell'asma acuto

Titolo del documento

Aerosol delivery to non-ventilated infants by metered dose inhaler: should a valved spacer be used ?

Autori e Nazionalità

Fok TF, Lam K, Chan CK, NG PC, Zhuang H, Wong W, Cheung Kl.Cina

Fonte bibliografica

Pediatr Pulmonol 1997;24:204-12

Lingua

Inglese

Abstract

In a randomized double-blind cross-over study on 20 spontaneously breathing, oxygen-dependent preterm infants who had received positive pressure ventilation for respiratory distress syndrome, we tested the hypothesis that the one-way non-rebreathing valves of aerosol spacer devices might impair rather than enhance the delivery of aerosols to small infants by metered dose inhalers (MDI). Ten infants were given 2 doses (200 micrograms/dose) of MDI albuterol through a neonatal Aerochamber 4 h apart. At random sequence, one dose was delivered with the non-rebreathing valve of the Aerochamber in place; for the other dose, the valve had been removed. The experiment was repeated on another ten infants using a different spacer device (Babyhaler) with or without its one-way inspiratory valve removed. During the first hour following aerosol administration, use of the non-valved spacers was associated with a significantly greater degree of tachycardia in both groups, and also lower transcutaneous carbon dioxide tension in the Aerochamber group. All infants showed a reduction in respiratory system resistance and an improvement in functional residual capacity following albuterol treatment. In both groups, maximum reduction in respiratory system resistance, recorded 30 min after aerosol delivery, was significantly greater following the use of the non-valved spacers (Aerochamber: 51.2 +/- 3.1% vs. 35.0 +/- 2.8%, P < 0.0001; Babyhaler: 38.8 +/- 2.3% vs. 19.2 +/- 1.4%, P < 0.0001) than following the use of the spacers with a valve. The findings provide indirect evidence supporting our hypothesis and suggest that when the MDI is used to deliver therapeutic aerosols to non-ventilated newborns or small infants, a spacer device without a non-rebreathing valve should be used

PMID

9330417 [PubMed - indexed for MEDLINE]

Tipo di studio

Osservazionale

Livello di evidenza

3

Commento

L'uso di una valvola sia nell'Aerochamber che nel Babyhaler determina una maggior riduzione delle resistenze respiratorie rispetto all'uso degli stessi apparecchi senza valvole quando si somministra  salbutamolo

Titolo del documento

Effects of instruction by practice assistants on inhaler technique and respiratory symptoms of patients. A controlled randomized videotaped intervention study

Autori e Nazionalità

Verver S, Poelman M, Bogels A, Chisholm SL, Dekker FW. Olanda

Fonte bibliografica

Family practice 1996;13:35-39

Lingua

Inglese

Abstract

BACKGROUND. Many patients with asthma or chronic obstructive pulmonary disease use their medication inhalers incorrectly. General practitioners, pharmacists and other health care providers do not always have the opportunity to instruct patients in correct inhaler technique. OBJECTIVE. To find out whether the inhaler technique and respiratory symptoms of patients can be improved after instruction by practice assistants. METHODS. Single blind, randomized intervention study in which 48 patients who had been using a dry powder inhaler for at least one month took part. Their inhaler technique was videotaped on two visits with a two-week interval between visits. The inhaler technique on the videos was subsequently scored by two experts on nine criteria. At both visits the patients completed a questionnaire about their respiratory symptoms. After the first video, 25 patients were randomly chosen to receive instruction from one of six practice assistants who had followed a one evening course about inhaler instruction, and who had been issued an instruction-set. RESULTS. The patients who received instruction had a significantly greater reduction in number of mistakes at the second visit than the patients who did not (P = 0.01). The instructed patients also reported less dyspnoea at the second visit (P = 0.03). No effect of instruction was found on wheezing, cough and sputum production. CONCLUSION. The inhaler technique of patients can be improved significantly by the instruction of patients by trained practice assistants, possibly resulting in less dyspnoea.

PMID

8671102 [PubMed - indexed for MEDLINE]

Tipo di studio

Livello di evidenza

Commento

La tecnica inalatoria dei pazienti può essere migliorato attraverso istruzioni e dimostrazioni eseguite da personale che conosce la metodica 

Titolo del documento

Inhalers and nebulizers: which to choose and why. Respir Med 1996;90:69-77

Autori e Nazionalità

Pedersen S 

Fonte bibliografica

Respir Med 1996;90:69-77

Lingua

Inglese

Abstract

It is obvious that many factors should be considered when an inhaler is prescribed. Based upon the information discussed above, a rational inhaler strategy could be as follows: (1) Children < or = 5 years and elderly patients are prescribed a spacer with a valve system (and a face mask for the children) for the delivery of all drugs. When they are severely obstructed, some may need a nebulizer. If the patient cannot be taught the correct use of a spacer, a nebulizer should be prescribed. (2) Children > or = 5 years and adults are prescribed a spacer or a Turbuhaler for the administration of inhaled corticosteroids and a dry powder inhaler (preferably multiple dose) or a breath-actuated MDI for other drugs. If these alternatives are not available or the patient prefers, a conventional MDI can be used (preferably not for other corticosteroids than fluticasone propionate) provided that careful tuition is given. Fluticasone dipropionate may be given by DPI, Spacer or MDI. (3) Nebulizers are mainly reserved for severe acute attacks of bronchoconstriction. With this approach, most patients can be taught effective inhaler use with a minimum of instructional time. Finally, it must always be remembered to consider the patient's wish, since prescription of an inhaler which the physician likes but the patient does not is likely to reduce compliance.

PMID

8730324 [PubMed - indexed for MEDLINE]

Tipo di studio

Revisione narrativa

Livello di evidenza

4

Commento

Una sintesi delle conoscenze (di 11 anni fa) sulla tecnica inalatoria relativa ai principali device ( MDI, spacer, polveri secche)

Titolo del documento

Parent satisfaction with services in an emergency department located at a paediatric teaching hospital

Autori e Nazionalità

Brown K, Sheehan E, Sawyeer M, Raftos J, Smith V. Australia

Fonte bibliografica

J Paediatr Child Health 1995;311(5):435-39.

Lingua

Inglese

Abstract

OBJECTIVE: To evaluate parents' satisfaction with the services provided in an emergency department located at a paediatric hospital. METHODOLOGY: A descriptive study in which the parents of children with non-life-threatening illnesses attending an emergency department completed a questionnaire describing their satisfaction with services in the department. RESULTS: The majority of parents were satisfied with the services provided. However, less satisfied parents reported having to wait significantly longer before receiving medical attention than satisfied parents. Consistent with this finding, 77% of less satisfied parents reported that staff did not attend to their children's needs quickly enough and 62% felt that there were insufficient staff available to provide help. Twenty-nine per cent of the less satisfied parents reported that they did not know what was required for the ongoing care of their children after their discharge from the emergency department. CONCLUSIONS: In order to address the concerns of less satisfied parents, emergency departments need to give careful attention to the maintenance of reasonable waiting times, the provision of adequate staffing, and the quality of staff-parent communication. Addressing these issues may improve the ongoing care of children after their discharge from emergency departments.

PMID

8554865 [PubMed - indexed for MEDLINE]

Tipo di studio

Osservazionale

Livello di evidenza

3

Commento

Uno studio che esamina il gradimento dei genitori che si sono recati al Pronto Soccorso con il proprio figlio

Titolo del documento

Effect of electrostatic charge, flow, delay and multiple actuations on in the in vitro delivery of salbutamol from different small volume spacers for infants

Autori e Nazionalità

Wildhaber JH, Devadason SG, Eber E, Hayden MJ, Everard ML, Summers QA, LeSouef PN. Australia

Fonte bibliografica

Thorax 1996;51:985-8

Lingua

Inglese

Abstract

BACKGROUND: A study was undertaken to determine the influences of electrostatic charge, flow, delay, and multiple actuations on the in vitro delivery of salbutamol generated by a pressurised metered dose inhaler (pMDI) from small volume spacers used in infants. METHODS: Ten actuations from a salbutamol pMDI were drawn at different flow rates after either single or multiple actuations, with or without delay, through either static or reduced static spacers. An ionic detergent was used to reduce the charge of plastic spacers (Babyhaler, Babyspacer, Aerochamber, Nebuhaler). Electrostatic charge was measured using an electrometer. A multistage liquid impinger was used to determine the particle size distribution of the output of the pMDI through the spacers. RESULTS: Electrostatic charge on the surface of plastic spacers had the greatest influence on delivery, causing a decrease in drug delivery. Reducing charge by coating the surface with ionic detergent resulted in an increase of 46.5-71.1% (p < 0.001) in small (< 6.8 microns) particle delivery from small volume plastic spacers. Lower flow, delay, and multiple actuations resulted in decreased delivery from static spacers. Lower flow resulted in a decrease of 15% in small (< 9.6 microns) particle delivery. Delay and multiple actuations resulted in a decrease of 40.7% and 76.0%, respectively, in small (< 6.8 microns) particle delivery. The influences of lower flow, delay, and multiple actuations were greatly reduced or even eliminated by reducing charge. However, multiple actuations still resulted in a significant decreased delivery (p < 0.05). The reduced static Nebuhaler had a higher delivery than all small volume spacers. CONCLUSIONS: Electrostatic charge has a major influence on the delivery of salbutamol from small volume spacers. Using a metal spacer or ionic detergent coating of plastic spacers resulted in no or reduced charge and hence in improved delivery. Lower flow, delay, and multiple actuations played a major part only in static spacers.

PMID

8977597 [PubMed - indexed for MEDLINE]

Tipo di studio

Osservazionale

Livello di evidenza

3

Commento

Il ritardo nell'inizio dell'inspirio e l'esecuzione di spruzzi multipli causano una riduzione del 40.7% e del 76% rispettivamente nell'erogazione delle particelle aerosoliche più piccole

Titolo del documento

Metered-dose inhalers with spacers vs nebulizers for pediatric asthma.

Autori e Nazionalità

Chou KJ, Cunningham SJ, Crain EF. Usa

Fonte bibliografica

Arch Pediatr Adolesc Med 1995;149:201-205

Lingua

Inglese

Abstract

OBJECTIVE: To determine whether the administration of beta-agonists by metered-dose inhaler (MDI) with a spacer device is as effective as the administration of beta-agonists by nebulizer for the treatment of acute asthma exacerbations in children. DESIGN: Randomized trial with two arms. SETTING: Urban pediatric emergency department (ED) in Bronx, NY. PATIENTS: Convenience sample of 152 children 2 years and older with a history of at least two episodes of wheezing presenting to the ED with an acute asthma exacerbation. INTERVENTIONS: Patients were randomly assigned to receive standard doses of a beta-agonist (albuterol) by an MDI with spacer or by a nebulizer. Dosing intervals and the use of other medications were determined by the treating physician. MEASUREMENTS/MAIN RESULTS: Baseline characteristics and asthma history were recorded. Asthma severity score, peak expiratory flow rate in children 5 years or older, and oxygen saturation were determined at presentation and before admission or discharge. The groups did not differ in age, sex, ethnicity, age of onset of asthma, or asthma severity score at presentation. There were no significant differences between the groups in outcomes, including mean changes in respiratory rate, asthma severity score, and peak expiratory flow rate, oxygen saturation, number of treatments given, administration of steroids in the ED, and admission rate. Patients given MDIs with spacers required shorter treatment times in the ED (66 minutes vs 103 minutes, P < .001). Fewer patients in the spacer group had episodes of vomiting in the ED (9% vs 20%, P < .04), and patients in the nebulizer group had a significantly greater mean percent increase in heart rate from baseline to final disposition (15% vs 5%, P < .001). CONCLUSIONS: These data suggest that MDIs with spacers may be an effective alternative to nebulizers for the treatment of children with acute asthma exacerbations in the ED.

PMID

7849885 [PubMed - indexed for MEDLINE]

Tipo di studio

Randomizzato

Livello di evidenza

1+

Commento

Spray con distanziatore vs nebulizzatore per somministrare i broncodilatatori nell'attacco acuto d'asma. 

Titolo del documento

Metered dose inhaler and nebuliser in acute asthma

Autori e Nazionalità

Lin YZ, Hsieh KH. Taiwan. 

Fonte bibliografica

Arch Dis Child 1995;72:214-8. 

Lingua

Inglese

Abstract

One hundred and eleven children with acute asthma were studied to compare delivery of terbutaline by either a metered dose inhaler (MDI) with a valved holding chamber or a nebuliser driven by air. Eligible patients were randomised; the MDI group received three puffs (0.75 mg) of terbutaline and the nebuliser group received 2 ml (5.0 mg) terbutaline solution diluted with 2 ml 0.9% saline for inhalation over 10 minutes. Patients were evaluated by spirometry, pulse oximetry, and clinical severity scoring system at baseline and again 15 minutes after the beginning of treatment. The baseline data of the two groups were not significantly different. All parameters of spirometry, except the peak expiratory flow (PEF) for the nebuliser group, and clinical severity score for both groups significantly improved after terbutaline treatment. Compared with the nebuliser group, the MDI group after treatment had better mean (SD) oxygen saturation (SaO2; 96.82 (1.63)% v 95.44 (1.88)%), frequency of oxygen desaturation (23.2% v 47.3%), absolute increase of PEF (32.6 (37.7) l/min v 10.2 (34.7) l/min), and SaO2 (0.54 (1.64)% v -0.47 (1.84)%). There was also a mean (SD) per cent increase of forced expiratory volume in one second (22.9 (21.0)% v 15.4 (16.1)%), PEF (27.7 (38.4)%) v 7.7 (25.1)%), and SaO2 (0.58 (1.72)% v -0.47 (1.93)%). In conclusion, aerosol treatment by MDI (with a valved holding chamber) in this study proved to be superior to nebuliser treatment in terms of SaO2 and some measurements of spirometry. Respiratory therapists working with children with severe asthma should be aware of the possibility of oxygen desaturation, especially when using room air as the driving gas for nebulisation.

PMID

7741566 [PubMed - indexed for MEDLINE]

Tipo di studio

Randomizzato

Livello di evidenza

1+

Commento

Spray con il distanziatore vs nebulizzatore per somministrare i broncodilatatori nell'attacco acuto d'asma.

Titolo del documento

Randomised trial spacer v nebuliser for acute asthma.

Autori e Nazionalità

Parkins PC, Saunders NR, Diamond SA, Winders PM, Macarthur C. Canada

Fonte bibliografica

Arch Dis Child 1995;72:239-240

Lingua

Inglese

Abstract

Sixty hospitalised children with asthma aged 1-5 years were randomised to spacer or nebuliser. A clinical score was measured at baseline and every 12 hours. There were no differences between groups in the score over time, or secondary outcome measures. The spacer is an effective delivery method for young hospitalised asthmatic children.

PMID

7741574 [PubMed - indexed for MEDLINE]

Tipo di studio

Randomizzato

Livello di evidenza

1+

Commento

Spray con il distanziatore vs nebulizzatore per somministrare i broncodilatatori nella terapia dell'attacco acuto d'asma.

Titolo del documento

Babyhaler-a new paediatric aerosol device.  

Autori e Nazionalità

Kraemer R. Svizzera

Fonte bibliografica

J Aerosol Med 1995;8 Suppl 2;S19-26.

Lingua

Inglese

Abstract

Nebulizers have, until recently, been the mainstay of drug delivery by inhalation in babies and young children. The willingness of a young child to cooperate, however, is limited and the 10-12 mins needed to deliver drug using a nebulizer often limits the compliance with this mode of administration in infants. Therefore, drug delivery systems using the metered-dose inhaler (MDI) as the aerosol generator attached to valved holding chambers were developed. The breathing pattern of a baby with lung disease is quite different from that of older children and adults, for whom most large-volume devices were developed. Infants have a high respiratory frequency, small tidal volume, and low inspiratory airflow rate. Therefore, specific conditions for optimal drug use in this particular group of patients have to be met. Efficacy of topical drug delivery depends on the generation of aerosol particles with an adequate size distribution (technical prerequisites), the breathing pattern of the child (physiological requirements), and the willingness of a young child to cooperate with parental drug administration (practicality and compliance). Infants with lung disease have a tidal volume of 8-10ml/kg body weight. The volume of a spacer device must be such that about 5-10 breaths would be needed to provide an adequate dose. In addition, the dimensions of a spacer device must be such that sufficient drug particles of optimal size will be generated to minimize impaction and deposition within the device. The Babyhaler consists of a tubular chamber 230mm long, with a volume of 350ml and low-resistance inspiratory and expiratory valves

PMID

10155355 [PubMed - indexed for MEDLINE]

Tipo di studio

Revisione narrativa

Livello di evidenza

4

Commento

Le caratteristiche del Babyhaler

Titolo del documento

What do pedaitricians in training know about the correct use of inhalers and spacer devices ?

Autori e Nazionalità

Amirav I, Goren A, Pawlowski NA. Israele

Fonte bibliografica

J Allergy Clin Immunol 1994;94:669-675

Lingua

Inglese

Abstract

Most patients with asthma in the United States are cared for by nonspecialist physicians. Because inhaled medications are the mainstay of asthma therapy and their successful use requires both practical skills and theoretic knowledge, we wondered how much nonspecialist physicians know about the use of metered-dose inhalers and spacer devices. Fifty pediatricians in training were interviewed individually. Practical knowledge was assessed by asking each to demonstrate correct use of a placebo inhaler and a spacer device (Inspirease [Key Pharmaceuticals, Inc., Miami, Fla.] and Aerochamber with mask [Monaghan Medical Corp., Plattsburgh, N.Y.]). Of the seven recommended steps for use of metered-dose inhalers, the residents demonstrated an average of 3.8 steps correctly. The most common errors included not shaking the metered-dose inhaler before use (18% of residents correct) and insufficient breath holding (28% correct). In testing spacer use, the most common errors included not shaking the canister (16% correct) and incorrect number of activations and inhalations (12% correct). Many residents were not familiar with correct assembly of the spacer (48% correct). Theoretic knowledge of metered-dose inhaler and spacer use was evaluated by a written questionnaire. The most common deficiencies in theoretic knowledge related to the purpose of slow inspiration and breath holding. Most of the participants had been treating children with asthma and had prescribed metered-dose inhalers (45 of 50, 90%) and spacer devices (76%) in the past

PMID

7930299 [PubMed - indexed for MEDLINE]

Tipo di studio

Osservazionale

Livello di evidenza

3

Commento

Anche gli specializzandi di pediatria non conoscono bene la tecnica dei distanziatori.....

Titolo del documento

Efficacy of albuterol administered by nebulizer versus spacer device in children with acute asthma 

Autori e Nazionalità

Kerem E, Levison H, Schuh s, O'Brodovich H, Reisman J, Bentur L, Canny GJ

Fonte bibliografica

J Pediatr

Lingua

Inglese

Abstract

The aim of this study was to compare the response to inhaled albuterol after administration by nebulizer with the response after administration by a metered-dose inhaler and spacer device (MDI-spacer) to children with acute asthma. In a double-blind fashion, 33 children (6 to 14 years of age) with forced expiratory volume in 1 second (FEV1) between 20% and 70% of predicted values, and who were seen in the emergency department with acute asthma, were studied. They were treated with aerosolized albuterol or placebo by MDI-spacer, followed immediately by albuterol or placebo administered by nebulizer with oxygen. The dose ratio for albuterol by MDI-spacer versus nebulizer was 1:5. Outcome measures included a clinical score, respiratory rate, arterial oxygen saturation, and FEV1, measured before and 10, 20, and 40 minutes after treatment. With the exception of heart rate (which increased in the nebulizer group and decreased in the MDI-spacer group (p < 0.05), no difference in the rate of improvement of clinical score, respiratory rate, arterial oxygen saturation, or FEV1 was noted during the 40-minute study period between children who received albuterol by nebulizer and those who received it by MDI-spacer. We conclude that spacers and nebulizers are equally effective means of delivering beta 2-agonists to children with acute asthma.

PMID

8345434 [PubMed - indexed for MEDLINE]

Tipo di studio

Randomizzato, in doppio cieco

Livello di evidenza

1+

Commento

Spray con il distanziatore vs nebulizzatore per somministrare i broncodilatatori nell'attacco acuto d'asma

Titolo del documento

Single breathversus panting technique in salbutamol delivery through a 750 ml spacing device

Autori e Nazionalità

James RW, Masters IB. Australia

Fonte bibliografica

Pediatr Pulmonol 1990;8(4):263-7

Lingua

Inglese

Abstract

Spacing devices have been widely advocated for asthmatic patients having difficulty actuating metered aerosols and co-ordinating inspiration. Studies have generally supported the slow inspiration/breath hold technique. This requires conscious respiratory control. Such control is often not possible in young children; consequently panting techniques are widely recommended. The panting technique has not been studied. The aim of this study was to compare the bronchodilator effectiveness of panting and the single breath maneuver, each followed by a breath hold, and each at functional residual capacity (FRC), using a Volumatic Space. The study design was a randomly allocated cross-over assessment of bronchodilator response for each technique. The drug dosage was controlled by limiting the inspired volumes of gas (single and cumulative) to the pretested inspiratory capacity. Two hundred micrograms of salbutamol was delivered into the spacer. Twenty-one patients were entered in the study and 15 (mean age +/- SD = 10.9 +/- 3.3 years) completed the protocol. There was no significant difference in bronchodilator response between the two groups. We conclude that the panting and the single breath techniques are equally effective in children of this age group.

PMID

2196513 [PubMed - indexed for MEDLINE]

Tipo di studio

Randomizzato, cross over

Livello di evidenza

2+

Commento

Utilzzando il Volumatic non c'è differenza nella risposta broncodilatatrice al salbutamolo utilizzando la tecnica del respiro singolo con inspirio profondo o quella di più atti respiratori tranquilli

Titolo del documento

Comparative efficacy of terbutaline administered by Nebuhaler and by nebulizer in young children with asthma.

Autori e Nazionalità

Pendergast J, Hopkins J, Timms B, Van Asperen PP. Australia.

Fonte bibliografica

Med J Aust 1989;151:406-8. Australia 

Lingua

Inglese

Abstract

We compared the use of terbutaline sulphate that was delivered by a nebulizer with its delivery by a Nebuhaler at two dose levels in 27 children (nine children per group) of between three and six years of age with acute asthma. No significant difference was found in the mean baseline clinical score among the three groups, and a significant decline occurred in the mean clinical scores in all groups by 15 minutes which was maintained to 60 minutes after the dose was administered. The decline that was achieved with delivery of the drug by way of a Nebuhaler (at either dose level) was not significantly different from that with a nebulizer, although cooperation with Nebuhaler usage was not universal in the age-group.

PMID

2677624 [PubMed - indexed for MEDLINE]

Tipo di studio

Randomizzato

Livello di evidenza

1+

Commento

Spray con il distanziatore vs nebulizzatore  per somministrare i broncodilatatori nella terapia dell'attacco acuto d'asma.

Titolo del documento

Pressure flow characteristics of the valve in spacer devices.

Autori e Nazionalità

Sennhauser FH, Sly PD. Australia 

Fonte bibliografica

Arch Dis Child 1989;64:1305-7

Lingua

Inglese

Abstract

The valve system in the mouth piece of two spacer devices was analysed. Pressures required to open and close the non-rebreathing valve were very low (less than 0.1 kPa). Inspiratory flow requirements were within physiological limits for infants' normal tidal breathing. Expiratory flow requirements varied significantly, and the flow required to prevent rebreathing from the chamber may exceed the physiological flow limits for normal tidal breathing.

PMID

2817951 [PubMed - indexed for MEDLINE]

Tipo di studio

Osservazionale

Livello di evidenza

3

Commento

Titolo del documento

Wet nebulizer versus spacer and metered dose inhaler via tidal breathing

Autori e Nazionalità

Ba M, Spier S, Lapierre G, Lamarre A. Ghana 

Fonte bibliografica

J Asthma 1989;26:355-8

Lingua

Inglese

Abstract

testo

PMID

2702242 [PubMed - indexed for MEDLINE]

Tipo di studio

Randomizzato

Livello di evidenza

1+

Commento

Spray con il distanziatore versus nebulizzatore per somministrare i broncodilatatori nell'attacco acuto d'asma

Titolo del documento

Nebuhaler technique

Autori e Nazionalità

Gleeson JG, Price JF.Gran Bretagna

Fonte bibliografica

Br J Dis Chest 1988;82(2):172-4

Lingua

Inglese

Abstract

Two Nebuhaler techniques were compared by measuring the response to terbutaline 0.25 mg in 13 asthmatic children. Five breaths each sufficient to operate the Nebuhaler valve resulted in greater bronchodilatation after 10 minutes (P less than 0.05) than two deep inspirations from residual volume each held for 5 seconds. The peak responses were similar and both methods produced significant bronchodilatation compared with placebo. Either method is satisfactory in children but the former is easier to perform.

PMID

3166930 [PubMed - indexed for MEDLINE]

Tipo di studio

Osservazionale

Livello di evidenza

3

Commento

Scarso numero di partecipanti

Titolo del documento

Errors in inhalation technique and efficiency in inhaler use in asthmatic children 

Autori e Nazionalità

Pedersen S, Frost L, Arnfred T. Danimarca 

Fonte bibliografica

Allergy 1986;41:118-124

Lingua

Inglese

Abstract

256 asthmatic children receiving regular inhalation therapy demonstrated how they used their inhalers. Pulmonary function measurements (PFM) were made before and after the demonstrations, and errors in technique were recorded. 242 children had reversible airway obstruction on the day of study. In only 109 (45%) did the inhalation result in an increase in FEV1 greater than or equal to 15% (efficient technique). An efficient inhalation technique was found in 46% of children who demonstrated a pressurized aerosol, 59% who demonstrated a tube spacer aerosol and 46% who demonstrated a rotahaler, and the frequency of efficient technique varied from 17% to 84% between six different groups of instructors. 87% of children controlled and 25% not controlled with PFM at the time of prescription had an efficient technique. Children under 6 years had a more inefficient and a more faulty technique than older children, but otherwise age did not influence the result. Neither was time since instruction of any importance for efficiency or number of errors. The errors recorded that seem to influence efficiency most were: coordination problems, rapid inspirations, ceasing to inspire when the aerosol was fired, and inhalation through the nose. The results emphasize the paramount importance of clear instructions and control of inhalation technique at the time the treatment is prescribed

PMID

3706674 [PubMed - indexed for MEDLINE]

Tipo di studio

Osservazionale

Livello di evidenza

2+

Commento

Molti errori vengono compiuti dai pazienti che usano la tecnica dello spray con il distanziatore: i più comuni sono quelli di non ricordarsi di scuotere lo spray e di non eseguire la pausa respiratoria

Titolo del documento

Nebuhaler versus nebulizer in children with acute asthma.

Autori e Nazionalità

Freelander M, Van Asperen PP

Fonte bibliografica

Br Med J 1984;288:1873-4. Australia

Lingua

Inglese

Abstract

testo

PMID

6428582 [PubMed - indexed for MEDLINE]

Tipo di studio

Randomizzato

Livello di evidenza

1+

Commento

Spray con il distanziatore vs nebulizzatore per somministrare i broncodilatatori nell'attacco acuto d'asma.