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PubMed1995

[Inhaled beclomethasone in long-term management of asthma: optimal dose and optimal duration of treatment].

We studied the usefulness of 24 weeks of therapy with inhaled beclomethasone dipropionate (BDP) in the management of mild and moderately severe asthma in adults. To determine the optimal dose and treatment duration, the patients were divided into three groups. Patients in group I (n = 10) were treated with bronchodilators but no BDP. Patients in group II (n = 12) received bronchodilators and 450 micrograms/day of BDP. Patients in group III (n = 17) received bronchodilators and 900 micrograms/day of BDP. BDP was inhaled via a large spacer (Volumatic). Asthma scores were measured before treatment began, and again every 2 weeks for the duration of the study (26 weeks). Peak expiratory flows (PEF) were measured before treatment began, 2 weeks after treatment had begun, and again every four weeks until the end of the study. Vital capacity, FEV1, and bronchial reactivity to methacholine were measured before treatment began, and again 12 weeks and 24 weeks after it had begun. Adrenocortical function in patients in group III was measured with a rapid ACTH test, at the same time as the pulmonary functions were measured. The results were: 1) Asthma scores decreased more in patients who received the higher dose of BDP than in those who received the lower dose, especially during the second 12 weeks. 2) After two weeks of treatment, %PEF had increased significantly in both groups that received BDP, but after six weeks of treatment there was no further improvement. %PEF did not improve in the group given bronchodilators only. 3) In the patients whose baseline %PEF was less than 80%, only the higher dose of BDP significantly increased %PEF. 4) Only the higher dose of BDP increased the %VC, the FEV1%, and the PD20 for methacholine. 5) Asthma type and severity were not related to the usefulness of BDP therapy. 6) Results of the rapid ACTH test indicated that the higher dose of BDP did not suppress adrenocortical function. These data indicate that 900 micrograms of BDP per day is more effective than 450 micrograms/day as initial therapy for long-term management of mild or moderate asthma in adults, and that the dose of BDP should be reviewed after 3 months of treatment. Patients in whom asthma is well-controlled may tolerate a reduction in dose, and those in whom asthma is not well-controlled may require a higher dose.

Administration, Inhalation↗
PubMed1996

Dose response study of ipratropium bromide aerosol on maximum exercise performance in stable patients with chronic obstructive pulmonary disease.

BACKGROUND: Although the bronchodilating effect of inhaled anticholinergics has been established in patients with chronic obstructive pulmonary disease (COPD), their effects on exercise capacity are still controversial. Previous studies have suggested that the standard dosage hardly affects exercise tolerance, whereas higher doses might elicit an improvement. The aim of the present study was to determine the dose of ipratropium bromide aerosol that improves exercise performance using progressive cycle ergometry in patients with stable COPD. METHODS: Twenty men with stable COPD of mean (SD) age 69.2 (4.6) years and forced expiratory volume in one second (FEV1) 1.00 (0.37) 1 were studied in a randomised double blind manner. Each patient received ipratropium bromide in doses of 240 micrograms, 160 micrograms, 80 micrograms, 40 micrograms, and placebo from a metered dose inhaler (MDI) with an InspirEase spacer on five separate days. Spirometric parameters were assessed before and at 30, 60, 90, and 120 minutes after each inhalation, and pulse rate and blood pressure were also measured immediately before each spirometric measurement. Symptom limited progressive (20 watts/min) cycle ergometer exercise tests were performed 90 minutes after each inhalation. RESULTS: Ipratropium bromide in doses of 160 micrograms and 240 micrograms produced a greater increase in FEV1 than 40 micrograms or 80 micrograms ipratropium bromide at all time points. Doses of 160 micrograms and 240 micrograms ipratropium bromide also produced greater increases in maximal work load and maximal oxygen consumption than placebo, whereas 40 micrograms and 80 micrograms ipratropium bromide did not. There was a weak correlation between the change in FEV1 and the change in maximal work load (r = 0.45). No differences were found in pulse rate or blood pressure between the treatment and placebo groups, and no side effects were noted throughout the study. CONCLUSIONS: A dose of at least four times the standard dose of ipratropium bromide from an MDI with a spacer device was necessary to improve maximal cycle exercise capacity in patients with stable COPD. Although the data from cycle ergometry cannot be directly applied to exercise performed during day to day activities, it is conceivable that the recommended doses of ipratropium bromide do not elicit the optimal clinical benefits.

Aerosols↗
PubMed1998

Reported difficulties in access to quality care for children with asthma in the inner city.

OBJECTIVE: To characterize perceived access and barriers to quality health care for asthma among the caregivers of children in the inner city. DESIGN: Multicenter, cross-sectional survey. SETTING: Eight sites in 7 major metropolitan US inner cities. PARTICIPANTS: A systematic sample of children with asthma, aged 4 to 9 years, and their caregivers who resided in census tracts in which at least 30% of the households were below the 1990 federal poverty guidelines, recruited from 25 primary care clinics and 13 emergency departments (EDs) from November 1, 1992, through October 31, 1993. RESULTS: Of the 1528 children enrolled, 1376 had physician-diagnosed asthma and form the basis of this report. This group was further divided into 284 children (20.6%) who met all recruitment criteria for severe asthma and 207 (15.0%) with mild asthma who met none. Of parents in the total sample, 95.6% reported a usual place for short-term asthma care for their child; 75.4% used the ED. Children with severe asthma were significantly more likely to use the ED than those with mild asthma (84.3% vs 63.0%; P<.01). A usual place for follow-up asthma care was reported by 96.7% of subjects. There were no differences in access or type of facility used by asthma severity. More than half the study group reported difficulty in accessing care for acute asthma attacks and for follow-up care with no differences by asthma severity. Among those with severe asthma, 47.5% used inhaled steroids or cromolyn, 52.8% used a spacer device if they had been prescribed a metered dose inhaler, and 21.2% of children older than 6 years were prescribed a peak flowmeter. Patients with mild asthma were significantly less likely to report use of all 3 items (steroids or cromolyn, 1.4%; spacer device, 15.4%; and peak flowmeter, 3.1%, respectively; P<.01). CONCLUSION: Although access to asthma care among children in US inner cities appears adequate as determined by the traditional measure of reporting a regular source of care, barriers are frequently reported, as are deficiencies in the quality of medical care.

Anti-Asthmatic Agents↗
PubMed1989

Aerosol bronchodilator delivery methods. Relative impact on pulmonary function and cost of respiratory care.

Thirty-six acutely III, hospitalized patients with acute exacerbations of obstructive airway disease and a greater than 10% increase in forced expiratory volume in 1 s after administration of aerosolized bronchodilator were randomized to receive either metaproterenol sulfate delivered by updraft-compressor nebulization (UDN) or terbutaline sulfate delivered by metered-dose inhaler (MDI) with a spacer. Serial analyses of pulmonary function measurements were performed with the use of 95% confidence intervals for the percentage response ratios of MDI to UDN. The response to MDI was at least equivalent to that of UDN, and MDI use was associated with no prolongation of hospital stay. Equivalent bronchodilation was achieved with MDI therapy with a lower daily charge for therapy for each patient and less respiratory therapist time. In hospitalized bronchodilator-responsive patients with acute exacerbations of obstructive airway disease, the MDI/spacer combination is the preferred approach when the status of the patient allows its use.

Aerosols↗
PubMed2001

Metered-dose inhaler: the emergency department orphan.

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

Acute Disease↗
PubMed2001

Cromolyn sodium for the prevention of chronic lung disease in preterm infants.

BACKGROUND: Chronic lung disease (CLD) frequently occurs in preterm infants (< 37 weeks gestational age) and has a multifactorial etiology including inflammation. Cromolyn sodium is a mast cell stabiliser that inhibits neutrophil activation and neutrophil chemotaxis. Therefore it is possible that cromolyn sodium might have a role in the prevention of CLD. OBJECTIVES QUESTION: in preterm infants, does the prophylactic administration of cromolyn sodium reduce the incidence of CLD, mortality or the combined outcome of mortality or CLD at 28 days of life without undue side effects? SEARCH STRATEGY: The search strategy used to identify studies was according to the guidelines of the Cochrane Neonatal Review Group. Searches were made of MEDLINE, EMBASE, CINAHL up to and including December 2000, the Cochrane Library 2000 Issue 4, personal files and reference lists of identified trials. The following terms were used: chronic lung disease, cromolyn sodium or cromoglycate. LIMITS: newborn, infant; human, clinical trial or controlled clinical trial or meta analysis or randomised controlled trial. No language restrictions were applied. SELECTION CRITERIA: Randomised or quasi-randomised controlled clinical trials involving preterm infants. Initiation of cromolyn sodium administration during the first two weeks of life. The intervention had to include administration of cromolyn sodium by nebulizer or metered dose inhaler with or without spacer device, versus placebo or no intervention. Eligible studies had to include at least one of the following outcomes: overall mortality, CLD at 28 days, CLD at 36 weeks corrected gestational age, or the combined outcome mortality or CLD at 28 days. Secondary outcomes included number of days on oxygen, number of days on mechanical ventilation, patent ductus arteriosus (PDA), air leaks [pulmonary interstitial emphysema (PIE), pneumothorax], any grade of intraventricular haemorrhage (IVH), necrotizing enterocolitis (NEC), sepsis and adverse effects due to cromolyn sodium. DATA COLLECTION AND ANALYSIS: We used the standard method for the Cochrane Collaboration as described in the Cochrane Collaboration handbook. Both investigators extracted and assessed all data for each study. Any disagreement was resolved by discussion. Relative risk (RR) and risk difference (RD) with 95% confidence intervals (CI) are reported for dichotomous outcomes and weighted mean difference (WMD) for continuous data. Number needed to treat was not calculated as no outcome showed a statistically significant RD. A fixed effect model was used for meta-analysis. MAIN RESULTS: Two eligible studies were identified with small numbers of infants enrolled. Prophylaxis with cromolyn sodium did not result in a statistically significant effect on the combined outcome, death or CLD at 28 days [RR 1.05 (95% CI 0.73, 1.52); RD 0.03 (95% CI -0.20, 0.27)], CLD at 28 days [RR 0.93 (95% CI 0.53, 1.64; RD -0.03 (95% CI -0.27, 0.20)], CLD at 36 weeks corrected gestational age [RR 1.25 (95% CI 0.43, 3.63); RD 0.08 (95% CI -0.29, 0.44)], CLD in survivors at 28 days [RR 0.97 (95% CI 0.58, 1.63); RD -0.02 (95% CI -0.29, 0.26)] or CLD in survivors at 36 weeks corrected gestational age [RR 1.04 (95% CI 0.38, 2.87); RD 0.02 (95% CI -0.40, 0.43)]. Prophylaxis with cromolyn sodium did not show a statistically significant difference in overall mortality [RR 1.31 (95% CI 0.52, 3.29); RD 0.06 (95% CI -0.13, 0.26)]. There were no statistically significant differences in the incidence of air leaks, NEC, IVH, sepsis, days on mechanical ventilation or PDA. No side effects were noted. REVIEWER'S CONCLUSIONS: There is currently no evidence from randomized trials that cromolyn sodium has a role in the prevention of CLD. Cromolyn sodium cannot be recommended for the prevention of CLD in preterm infants. Additional clinical trials do not appear to be justified using the protocols for drug administration used to date unless a more efficient type of delivery device than the jet nebulizer is employed.

Chronic Disease↗
PubMed2003

Normal peak expiratory flow rate in urban and rural children.

OBJECTIVE: To establish a reference value of peak expiratory flow rates (PEFR) of normal boys and girls of urban and rural areas aged 6 to 15 years from Kamataka, South India and compare with other studies. METHODS: Twelve schools from urban and rural areas were selected to participate in the study. The permission was taken from the principal and the parents of the students from I to IX standards. A total of 6568 students participated in the study from 1994 to 1999. Among them 1091 children, were excluded from the study, who had respiratory symptoms and low peak expiratory flow rates who responded well to Salbutamol inhalation therapy in a spacer of 750 ml in volume. RESULT: A total of 5477 normal children were selected for the study. 2838 (51.8%) were boys; 2639 (48.2%) were girls. 4817 (87.9%) were from urban area and 660 (12.1%) were from rural areas. PEFR values correlated best with height, there was no difference in sexes, religion and urban/rural children.

Adolescent↗
PubMed2000

Mapping PET-measured triamcinolone acetonide (TAA) aerosol distribution into deposition by airway generation.

The three dimensional (3D) distribution of inhaled drugs was measured using Positron Emission Tomography (PET) (Berridge, M.S, Muswick, G.J., Lee, Z., Leisure, G.L., Nelson, A.D., Muzic, R.F. Jr., Miraldi, F., Heald, D.L., 1997. PET evaluation of Azmacort(R) ([C-11]triamcinolone acetonide) dose administration. J. Nucl. Med. 38 (5) Suppl., 4-5). Data analysis was based upon regional ratios or penetration indices. To improve the analytical usefulness and objectivity, labeled drug from dynamic PET images was mapped into 23 airway generations following a general framework from a SPECT-based methodology (Fleming, J.S., Nassim, M.A., Hashish, A.H., Bailey, A.G. , Conway, J., Holgate, S., Halson, P., Moore, E., Martonen, T.B., 1995. Description of pulmonary deposition of radiolabeled aerosol by airway generation using a conceptual three dimensional model of lung morphology. J. Aerosol Med. 8, 341-356). A recently developed airway network model was used in this study. Quantitative PET scans of [C-11]triamcinolone acetonide distribution in the lung were determined following administration of Azmacort(R), a commercial metered dose inhaler with an integrated spacer device. Distributions at varying time periods after drug administration were investigated to explore the dynamics and kinetics of the aerosolized drug. Initially, deposition of labeled drug on conducting airways (generations 1-14) was found to be higher than those on acinar airways (generation 15-23), 64% versus 36%. The distribution pattern changed slowly with time. By 47 min, 51% of the dose remaining in the lung was found on conducting airways while 49% was on acinar airways. This study illustrates the value of PET imaging for the evaluation and design of drug formulations.

Aerosols↗
PubMed1997

A new index for early prediction of hospitalization in patients with acute asthma.

Data from studies using the factor analysis technique have shown that asthma appears to be multidimensional and that most of the subjective and objective measures utilized in the assessment of asthma patients represent a much smaller number of underlying dimensions. Additionally, several investigators have emphasized that evaluation of acute asthma is an ongoing process, as the degree and time course of the response to therapy vary considerably between patients. The aim of this study was to examine the usefulness of the most common clinical and objective measures in the evaluation of acute asthma in the emergency department (ED) for predicting the outcome of acute episodes in adults. In an effort to identify variables that can predict the outcome of patients with acute asthma, 184 adults (age 32.4 +/- 11.6 [mean +/- SD]) (analysis sample) who presented to an ED were studied. The inclusion criteria were: (1) age between 18 and 50 years; (2) a peak expiratory flow rate (PEFR) or forced expiratory volume in the first second (FEV1) below 50% of predicted; and (3) no history of chronic cough or cardiac, hepatic, renal, or other medical disease. All patients were treated with salbutamol delivered with metered-dose inhaler (MDI) into a spacer device in 4 puffs actuated at 10-minute intervals and 500 mg of intravenous hydrocortisone. The multivariate statistical technique of discriminant analysis was utilized to develop the index, and after this, a new sample (n = 91), the validation sample, was studied to validate the index. In the analysis sample 163 patients (89%) were discharged (relapse rate within 7 days = 10%) and 21 (11%) were hospitalized (mean duration of hospital stay = 5.75 +/- 2.81 days). The discriminant analysis identified three independent variables that make the greatest contribution in discriminating between the two groups studied: PEFR variation over baseline, PEFR as percent of predicted, and accessory muscle use, all measured at 30 minutes after the beginning of treatment. A multifactorial index using these three variables presented a sensitivity of 0.86, a specificity of 0.96, a positive predictive value of 0.75, and a negative predictive value of 0.98. The validation sample index sensitivity, specificity, and positive and negative predictive values were 0.83, 0.97, 0.83, and 0.97, respectively. In conclusion, a predictive index has been developed for evaluating patients with asthma who present to an ED. This simple and brief three-item index can facilitate an early decision (30 minutes of treatment) to hospitalize patients with severe asthma.

Acute Disease↗
PubMed1996

Delivery of albuterol in a pediatric emergency department.

STUDY OBJECTIVE: To determine if albuterol delivery by the combination of a metered-dose inhaler (MDI) with a spacer is equal in effectiveness to nebulization in a pediatric emergency department setting. DESIGN: Prospective series. SETTING: Urban children's hospital emergency department. PARTICIPANTS: Patients > or = six years of age with the diagnosis of acute asthma exacerbation. Exclusion criteria consisted of impending respiratory failure and corticosteroid administration within the preceding seven days. INTERVENTIONS: Patients were randomized into either the nebulizer treatment group or one of two MDI-spacer treatment groups (two spacers were evaluated). Each patient received three albuterol treatments administered evenly over one hour. The dose ratio for albuterol by nebulizer versus MDI-spacer was 6.9:1. Outcome was assessed by comparing the pre- and posttreatment percent predicted respiratory rate and percent predicted peak expiratory flow rate (PEFR) for each patient. RESULTS: Sixty patients were enrolled in the study. All three treatment groups showed significant improvement following albuterol therapy in both percent predicted respiratory rate and percent predicted PEFR. When comparing the three groups against each other in regard to outcome, no significant differences were found in improvement of percent predicted respiratory rate (P = 0.3258) or percent predicted PEFR (P = 0.9362). CONCLUSION: In a pediatric emergency department setting, aerosolized albuterol delivered by MDI-spacer was equal in effectiveness to nebulization in the acute asthma management of children > or = six years of age.

Adrenergic beta-Agonists↗
PubMed1998

Bronchodilator response in 3-6.5 years old healthy and stable asthmatic children.

Few data are available on the bronchodilator response in preschool children. This study was set up to study baseline lung function and bronchodilator responses in healthy and asthmatic children younger than 7 yrs old. In 281 preschool children attending kindergarten (age range 2.7-6.6 yrs old) respiratory system resistance (Rrs) and reactance (Xrs) by impulse oscillation system at 5, 10, 15, 20, 25 and 35 Hz as well as resonance frequency (f0) were measured before and 20 min after 200 microg inhaled salbutamol by a metered-dose inhaler connected to a spacer device. Thirty-four of them were diagnosed as asthmatics based on a validated standardized questionnaire. The mean Rrs (+/-SD) at 5 Hz (Rrs,5) was 1.03 (+/-0.24) kPa x L(-1) x s for healthy children and 1.09 (+/-0.26) kPa x L(-1) x s for stable asthmatics. The mean change in Rrs,5 after salbutamol was -0.13 (+/-0.20) kPa x L(-1) x s for the healthy children and -0.09 (+/-0.25) kPa x L(-1) x s for the asthmatic group. The scatter for the measurements was striking. Neither baseline values of impulse oscillation nor its changes after bronchodilator administration was significantly different between healthy and stable asthmatic children. A change in respiratory system resistance at 5 Hz of 40% is to be considered the cut-off for a " positive" bronchodilator response.

Adrenergic beta-Agonists↗
PubMed1996

Results of a program to improve the process of inpatient care of adult asthmatics.

OBJECTIVE: To assess the effectiveness of a program to improve care of adult patients hospitalized for asthma. DESIGN: Retrospective analysis of patient and house staff education, patterns of medication use, spacer use, peak flowmeter use, and length of stay before and after team intervention. SETTING: A 960-bed teaching hospital in New York City. PATIENTS: All patients admitted to the hospital with a primary diagnosis of acute asthma exacerbation for 2 separate similar calendar periods, 1 year apart, before and after program intervention. We excluded patients who were hospitalized for less than 24 h or greater than 10 days. The preintervention group comprised 61 patients and the postintervention group 65 patients, well matched in their demographic characteristics and severity of disease. INTERVENTIONS: Using a team approach, we analyzed the process of inpatient treatment of asthma exacerbation, identified root causes for quality deficiency, and implemented specific improvements in the process. These included dedicated nurses who focused on the education of care providers and patients, a personalized attending-intern educational approach, and improvement in the supply and delivery of spacers, peak flowmeters, and medications to the patients. RESULTS: There was a significant increase in use of spacers, peak flowmeters, and inhaled corticosteroids. Systemic corticosteroid and methylxanthine use declined. Length of stay was reduced without increasing early hospital readmission rates. CONCLUSIONS: This program improved the treatment process of adults hospitalized for asthma.

Acute Disease↗
PubMed1985

Aerosol deposition considerations in inhalation therapy.

Successful aerosol therapy generally depends on the small percentage (typically 10 percent) of the drug dose delivered to the lungs from metered-dose inhalers (MDIs), nebulizers, and dry powder inhalers. Deposition of therapeutic aerosols occurs by inertial impaction (in the oropharynx and large conducting airways) and by gravitational sedimentation (in the small conducting airways and alveoli) and is determined by the mode of inhalation, particle or droplet size, and the degree of airway obstruction. Deposition of metered-dose aerosols in the lungs can be enhanced by using MDIs correctly (aerosol release coordinated with slow, deep inhalation, followed by a period of breath-holding); many patients have poor inhaler technique. Extension devices (spacers and holding chambers) make MDIs easier to use and may increase lung deposition to levels achieved by a correctly used MDI while substantially reducing oropharyngeal deposition. Optimal use of air-driven (jet) nebulizers depends primarily on the choice of nebulizers with relatively small droplet size and on the volume fill and compressed gas flow rate.

Aerosol Propellants↗
PubMedDate not supplied

Skin reactions to inhaled corticosteroids. Clinical aspects, incidence, avoidance, and management.

Inhaled corticosteroids are considered by many to be the therapy of choice in the treatment of asthma and allergic rhinitis. Systemic adverse effects are well known and are mainly dose dependent. Adverse cutaneous effects have also been characterized. Some of them are frequent and dose dependent, for example thinning of the skin and easy bruising. These adverse effects are probably present in about half of the patients treated with inhaled corticosteroids. The risk of these adverse effects is more important among elderly people and increases with the duration of the treatment and the daily dosage. Thinning of the skin and easy bruising are probably dependent on collagen synthesis modifications. Among rare or underestimated reactions, several adverse effects have been described such as angina bullosa hemorrhagica, acne and allergy. In this latter case, the attention should be paid to relevant clinical signs such as eczematous lesions of the face and aggravation of the nasal symptoms. Mucocutaneous infections related to inhaled corticosteroid use have also been reported, the most frequent being candidiasis. However, the frequency of symptomatic clinical infection is very rare. The risk of viral infection, especially with a herpes virus, has never been described. As cutaneous complications of corticosteroids are mainly dose dependent, these adverse effects could be prevented by attention to the daily dosage. Infection could be prevented by rising the mouth after inhalation and the use of a spacer device. If cutaneous adverse effects occur despite proper use of the inhaled corticosteroids and became unpleasant for the patient, discussion with a pneumologist or otorhinolaryngologist may be required but temporary halting therapy is rarely useful.

Administration, Inhalation↗
PubMed1986

A comparison of two delivery methods for aerosolized metaproterenol sulfate.

The bronchodilator response to metaproterenol sulfate delivered by metered-dose inhaler (MDI) with a spacer device (Aerochamber) and by jet nebulizer was studied in 15 asthmatic patients. The mean percent increase in absolute forced expiratory volume in 1 second (FEV1) with an MDI plus Aerochamber was 28.6%, and 28.8% with jet nebulization. There were no significant differences in the mean percent increases in FEV1, forced vital capacity (FVC), maximum midflow rate (MMFR), and peak expiratory flow rate (PEFR) with the two delivery methods. It is concluded that there is no difference in the bronchodilator responses to metaproterenol sulfate delivered by MDI plus Aerochamber or by jet nebulizer. The MDI plus Aerochamber has the advantage of being less expensive and more convenient to use.

Aerosols↗
PubMedDate not supplied

Inhaled corticosteroid delivery systems: clinical role of a breath-actuated device.

Several devices have been developed to overcome the need to co-ordinate actuation with inhalation required during use of a pressurised metered dose inhaler (MDI) and to improve drug delivery to the lung. These include spacer attachments for MDIs, dry powder inhalers and breath-actuated MDIs. The breath-actuated Autohaler (3M Pharmaceuticals) is a compact, multidose inhaler device that, unlike dry powder inhalers, does not rely on the patient's inspiratory effort to aerosolise the dose of medication. Due to its simple operation, the Autohaler is suitable for patients unable to operate a conventional MDI efficiently, including the elderly, children, patients with arthritis and patients with low inspiratory flow rates. The mandatory replacement of chlorofluorocarbon propellants with non-ozone-depleting propellants has given the opportunity to improve drug delivery characteristics of MDIs. Recently, a formulation of beclomethasone dipropionate in hydrofluoroalkane-134a (HFA-BDP), has been developed in a conventional MDI that delivers most of the emitted dose to the lung. Drug deposition studies show that the HFA-BDP formulation in the Autohaler device has a similar lung deposition pattern to drug delivered from the MDI, when used correctly, and dose delivery is consistent across a wide range of inspiratory flow rates. Furthermore, HFA-BDP Autohaler has similar clinical benefits to CFC-BDP Autohaler but at less than half the dose. HFA-BDP Autohaler offers a useful CFC-free delivery option for patients challenged by the conventional MDI device.

Administration, Inhalation↗
PubMed1991

Evaluation of a system for the delivery of inhaled beclomethasone dipropionate to intubated neonates.

Since systemic dexamethasone therapy for bronchopulmonary dysplasia is associated with numerous side effects, a simple system to deliver aerosolized beclomethasone dipropionate (BDP) directly to the lungs of intubated neonates was developed and evaluated in vitro. The system consists of a self-inflating bag, metered dose inhaler (MDI) adapter, Tygon spacer and endotracheal tube (ETT). A dose is delivered by discharging the MDI into the system and giving 3 'breaths' with the bag. Different sizes of ETT do not affect the drug output (1.17 +/- 0.29 vs. 1.32 +/- 0.34 micrograms of BDP per dose using a 3.0-mm or 3.5-mm ETT, respectively; means +/- SD). However, a shorter system spacer substantially reduces the drug output. The majority (54.0%) of the particles exiting the ETT and available to the patient are in the respirable range (0.5-5.5 microns). Based on adult doses and delivery of BDP and the relative sizes of the adult and neonatal lung, it is estimated that a neonate will require 1-6 doses/day. Replacing dexamethasone in the treatment of bronchopulmonary dysplasia with aerosol topical steroids delivered by this system may improve both the safety and efficacy.

Aerosols↗
PubMed2006

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

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.

Administration, Inhalation↗