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PubMed1996

Asthma therapy with aerosols: clinical relevance for the next decade.

Inhaled therapy is the mainstay of modern asthma management, as this optimizes the therapeutic ratio. Short-acting beta 2-agonists are the most effective bronchodilators and when given by inhalation give rapid relief of symptoms, without adverse effects, although there are concerns about overuse of these drugs. Inhaled long-acting beta 2-agonists are useful in some patients. Inhaled anticholinergics are particularly useful in patients with COPD and in the future long-acting drugs, such as tiotropium bromide, will be available. Inhaled glucocorticoids are the most effective therapy in controlling chronic asthma symptoms, and systemic effects are not a problem in the vast majority of patients. Improved inhalation devices and steroids with reduced oral bioavailability have resulted in reduced systemic side effects, which now arise largely from absorption from the lungs. In the future it is likely that new classes of drug will be developed, but whether they will be used by inhalation or given by mouth will depend on the frequency of side effects and the mode of action of the drugs. There are likely to be several improvements in inhaler delivery systems, so that the inhaled route will remain predominant for many years to come.

Administration, Topical↗
PubMed2000

Theoretical and experimental comparison of constant inspired concentration and pulsed delivery in NO therapy.

OBJECTIVE: Inhaled NO therapy of artificially ventilated patients has been established as being based on constant inspired concentration of NO. In this study a new volumetrically controlled pulsed NO delivery mode is compared with the established concentration-based concept. DESIGN: To evaluate the relationship between NO delivery parameters, alveolar NO fraction, and patient uptake, a mathematical lung model was created where NO delivery can be simulated in varying ventilator settings, delivery modes, and lung properties. This model and the efficacy of pulsed delivery in inducing pulmonary capillary vasodilatation were examined experimentally. SETTING: Animal laboratory, Department of Medical Sciences, Clinical Physiology. SUBJECTS: The experimental study was performed with nine pigs of mixed breed weighing 25-35 kg. INTERVENTIONS: The pigs were anaesthetised and artificially ventilated. Pulmonary vasoconstriction was induced by hypoxia. NO was delivered periodically in the various delivery modes. MEASUREMENTS AND RESULTS: In simulation, in all delivery modes the NO uptake was found to be dependent on the ventilator settings and the volume of the dead space. Measured from pulmonary artery pressure, the pulsed delivery was as effective in reducing the induced pulmonary vasoconstriction as the constant inspired concentration delivery. The amount of NO that could reduce the vasoconstriction back to baseline was 105 nmol x min(-1). By delivering in the early part of the inspiration, ambient contamination by the exhaust gas is avoided. The expired NO values obtained in the simulation and the experiments were equal. Based on the simulation, the alveolar NO fraction and the NO uptake depend on the ventilator settings and the dead space in both volumetric- and concentration-based delivery. CONCLUSIONS: With pulsed delivery, a therapeutic effect comparable to constant inspired concentration delivery is achieved, NO gas is used more effectively, and environmental exhausts are reduced. The theoretical model shows that the NO delivery does not predict alveolar NO fraction and the NO uptake. However, it still remains an open question if the online measurement of these parameters would provide useful information, having added value in predicting and controlling the efficacy of the NO treatment.

Animals↗
PubMed2006

Inhaled nitric oxide therapy in premature newborns.

PURPOSE OF REVIEW: Inhaled nitric oxide therapy reduces the need for extracorporeal membrane oxygenation in near-term and term newborns with hypoxemic respiratory failure and persistent pulmonary hypertension, and is now a standard of care for this population. There is also considerable interest, however, in the potential role of inhaled nitric oxide in premature newborns with hypoxemic respiratory failure. The purpose of this review is to summarize the results of clinical trials of inhaled nitric oxide in premature newborns, with particular emphasis on studies published in the last 12 months. RECENT FINDINGS: Several trials of inhaled nitric oxide in premature newborns with respiratory failure have been published in the last year. Interpretation of the findings is complicated by differences in the severity of illness of the study populations, the trial designs, and relevant outcome measures recorded. SUMMARY: Trials of inhaled nitric oxide in premature newborns have yielded conflicting results to date, and the role of inhaled nitric oxide therapy in this population remains controversial. The largest trials of inhaled nitric oxide therapy in premature newborns have completed enrollment but have yet to be published. The results of these ongoing trials will help clarify the potential risks and benefits of inhaled nitric oxide therapy in the premature newborn.

Administration, Inhalation↗
PubMed1986

Reversible airway obstruction: neurohumoral mechanisms and treatment. Lecture on asthma: clinical overview.

Asthma is an airway obstruction which is reversible, either spontaneously or in response to treatment. Repeated peak expiratory flow rate (PEFR) measurements, up to six times daily, allows this characteristic reversibility to be recognised, to guide diagnosis and therapy. Chronic asthmatics may eventually become relatively irreversible, and then appear similar to chronic bronchitics - unless an adequate history is taken. The commonest world-wide allergen is the fecal pellet of the house mite. Modern therapy of asthma starts with inhaled beta 2 agonists, but difficulty in using metered dose inhalers is helped by the 'spacer', or reservoirs (e.g. 'Nebuhaler'). Interaction between slow-release oral theophyllines and beta 2 agonists by inhalation maximises bronchodilatation but minimises tremor. High-dose ipratropium inhalation, as isotonic wet nebulisation with a beta 2 agonist, is useful in acute severe asthma. High doses of inhaled topical steroid are valuable in the difficult asthmatic, but pituitary adrenal suppression occurs if dosage exceeds 1,500 micrograms/day. Cromoglycate and a beta 2 agonist by inhalation can prevent exercise-induced asthma. Long-term oral steroids (never over 10 mg/day) are only used if inhaled therapy (+/- oral slow-release theophyllines) fails. Acute severe asthma needs parenteral steroid, parenteral beta 2 agonist, high-dose beta 2 agonist by inhalation, oxygen and hospital admission. Ventilation is increased in the acute severe asthmatic with hypoxia and low PCO2. In 90 asthmatic deaths surveyed in Britain, half had failed to realise the severity.

Administration, Topical↗
PubMed1997

Therapeutic options for severe pulmonary hypertension.

Pulmonary hypertension occurs as a consequence of numerous and varied conditions, all of which result in an elevation of pulmonary vascular resistance. Over the past decade, significant progress has been made in understanding the factors which contribute to the progressive nature of pulmonary vascular disease, and in identifying new treatments for pulmonary hypertension. The majority of these therapeutic options are pharmacologic, but for specific circumstances, surgical therapy may be a consideration. This article discusses nonspecific therapies for all patients with pulmonary hypertension, vasodilator therapy (including screening for vasodilator responsiveness, standard oral agents, and newer intravenous or inhalational therapies) and surgical options applicable to specific situations.

Anticoagulants↗
PubMed1999

Nitrogen dioxide formation during inhaled nitric oxide therapy.

BACKGROUND: Nitrogen dioxide (NO2) is a toxic by-product of inhalation therapy with nitric oxide (NO). The rate of NO2 formation during NO therapy is controversial. METHODS: The formation of NO2 was studied under dynamic flows emulating a base case NO ventilator mixture containing 80 ppm NO in a 90% oxygen matrix. The difficulty in measuring NO2 concentrations below 2 ppm accurately was overcome by the use of tunable diode laser absorption spectroscopy. RESULTS: Using a second-order model, the rate constant, k, for NO2 formation was determined to be (1.19 +/- 0.11) x 10(-11) ppm-2s-1, which is in basic agreement with evaluated data from atmospheric literature. CONCLUSIONS: Inhaled NO can be delivered safely in a well-designed, continuous flow neonatal ventilatory circuit, and NO2 formation can be calculated reliably using the rate constant and circuit dwell time.

Administration, Inhalation↗
PubMed2004

Clinical analysis of interstitial pneumonia after surgery for lung cancer.

OBJECTIVE: The postoperative development or exacerbation of interstitial pneumonia (IP) in lung cancer patients often affects prognoses. We analyzed the patients who suffered from IP after surgery, to determine treatment and prevention of IP. METHODS: One hundred and one consecutive patients who underwent resection were enrolled in the study. Clinical background and post-, perioperative course were compared between patients who developed IP and those who did not. RESULTS: If IP developed or was exacerbated, steroid pulse (SP) therapy, immunosuppressant (IS) therapy or nitric oxide (NO) inhalation therapy was employed. Of 101 patients, 20 had suffered from IP before surgery. In four of these 20 (20%), postoperative exacerbation was observed. SP therapy was given to all patients. To one patient, IS and NO therapy were added. Three of the four patients died. 81 patients did not have IP; three of them (3.7%) developed IP after the operation and were treated with SP therapy. To one patient, IS and NO therapy were added. Two of the three patients died. IP development or exacerbation after surgery was observed in seven of 101 patients, and five of them died. It was significantly more frequent in patients with poorly differentiated squamous cell carcinoma, restrictive change in pulmonary function tests, and a low percentage diffusion capacity for carbon monoxide. Postoperative development or exacerbation was observed in patients who had undergone lobectomy or pneumonectomy. CONCLUSIONS: Postoperative IP is a serious complication. Further studies are needed to determine definitive therapeutic options. For the patients with the aforementioned risk factors, limited surgery must be considered.

Adenocarcinoma↗
PubMed2001

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

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.

Administration, Inhalation↗
PubMed2004

Successful use of DPI systems in asthmatic patients--key parameters.

Effective inhalation therapy using pressurised metered dose inhalers (pMDIs) and dry powder inhalers (DPIs) is the cornerstone of asthma management. Previous studies have demonstrated difficulties in the usage of pMDIs in certain patient groups, especially as pMDis require the co-ordination of inhaler activation with dose inhalation. Almost all DPIs are breath-activated and preclude the need to co-ordinate activation with inspiration. Three key parameters for successful inhaler use should be considered when evaluating existing or future DPI devices: (1) compliance; (2) fine particle distribution and dependency on inspiratory flow and; (3) clinical efficacy. A threshold mechanism which controls for a minimal inspiratory flow rate is desirable in order to support formation of an optimal fine particle fraction (FPF) which in turn improves lung deposition. Additionally, in order to enhance patient compliance an optimal multidose DPI should feature a visual or acoustic feedback of a correct inhalation. The Novolizer is a multidose refillable DPI. It has multiple feedback mechanisms and a trigger flow valve system, which helps to ensure correct inhalation that allows adequate lung deposition, helps to reassure the patient that medication has been taken and might therefore improve patient compliance. The low-to-medium airflow resistance translates into higher peak inspiratory flow (PIF) and makes the Novolizer DPI particularly suitable for the use in patients with reduced inspiratory flow rates. Clinical studies have shown that children, elderly patients, adults with moderate-to-severe asthma and COPD patients (stage IIa-III) are able to generate sufficient inspiratory flow to operate the Novolizer effectively. In contrast previous studies with other MDPIs (e.g. Turbuhaler or Aerolizer) demonstrated that in patient groups with severe obstructive lung disease or in children with asthma optimal inspiratory flow rates are not achieved in all patients.

Administration, Inhalation↗
PubMed2000

Chlamydia pneumoniae serology, lung function decline, and treatment for respiratory disease.

Associations have been reported between Chlamydia pneumoniae seropositivity and both acute and chronic obstructive airway diseases. Plasma specimens collected between 1979 and 1983 from 1, 773 men 45 to 59 yr of age in Caerphilly, South Wales, were tested for IgG and IgA antibodies to C. pneumoniae (TW183) by microimmunofluorescence. Subsequent mortality and medication for obstructive airway disease were ascertained at 5-yr follow-up examinations. Spirometry was performed at the first and second examinations and analyzed both cross-sectionally and longitudinally; 642 men (36%) had IgG antibodies at a titer of 1:16 or above, of whom 362 also had detectable IgA antibodies. No statistically significant associations were found between either IgG titer or IgA titer and any of the outcome measures: inhaler therapy at entry; commencement of inhalers during follow-up; death from respiratory causes; baseline FEV(1), FVC, and FEV(1)/FVC ratio; and decline in FEV(1) (p > 0.1 throughout). Men with high IgG titers (>/= 1:64) had a slower rate of decline of FEV(1) than did seronegative subjects (adjusted mean difference in 5-yr change in FEV(1): +22 ml, 95% confidence interval: -31 ml to +76 ml). Men with high IgA titers (>/= 1:16) had a slightly faster rate of decline (-12 ml, - 96 ml to +71 ml). This first prospective assessment suggests that chronic C. pneumoniae infection is not a major risk factor for progressive airflow obstruction.

Antibodies, Bacterial↗
PubMed1996

Fluticasone propionate: safety profile.

Fluticasone propionate is a potent fluorinated corticosteroid used for the topical therapy of dermatoses and as inhalation therapy for bronchial asthma and allergic rhinitis. This agent has a good safety profile with a low propensity for systemic side effects, such as suppression of the hypothalamic-pituitary-adrenal (HPA) axis, and a low incidence of local side effects such as pruritus, burning, or skin atrophy. The pharmacologic properties of fluticasone propionate-including high lipophilicity, high selectivity and affinity for the glucocorticoid receptor, low systemic absorption, and rapid metabolism and clearance-combine to give fluticasone propionate a high therapeutic index.

Administration, Topical↗
PubMed2005

Regional variation in ICU care for pediatric patients with asthma.

OBJECTIVE: To determine adherence to guidelines for severe asthma care and evaluate regional variability in practice among pediatric intensive care units (PICU). STUDY DESIGN: A retrospective cohort study of children treated for asthma in a PICU during 2000 to 2003. We utilized the Pediatric Health Information System (PHIS) database to identify patients and determine use of asthma therapies when patients did not improve with standard therapy (inhaled beta-agonists and systemic corticosteroids). RESULTS: Of 7125 children studied, 59% received inhaled anticholinergic medications. Use of other therapies included systemic beta-agonists (n = 1841 [26%]), magnesium sulfate (n = 1521 [21%]), methylxanthines (n = 426 [6%]), inhaled helium-oxygen gas mixture (heliox) (n = 740 [10%]), and endotracheal intubation with ventilation (n=1024 [14%]). Use of therapies varied by census region. Over half the patients (n = 524) who received ventilation did so for < or = 1 day. Adjusted for severity of illness, use of mechanical ventilation varied significantly by census division; however, much of the variation was among children ventilated for < or = 1 day. CONCLUSION: Adherence to national guidelines for use of inhaled anticholinergics among critically ill children is low, and marked variation in use of invasive ventilation exists. More explicit guidelines regarding indications for invasive ventilation may improve asthma care.

Anti-Asthmatic Agents↗
PubMed2006

Long-term experience with oral or inhaled vasodilator combination therapy in patients with pulmonary hypertension.

BACKGROUND: Disease progression in pulmonary hypertension (PH) is common despite standard vasodilator monotherapy with iloprost, bosentan or sildenafil. OBJECTIVE: To investigate if the combination of these non-invasively applicable treatments is an effective option to address the multiple pathophysiological mechanisms present in PH. METHODS: We analysed the clinical course of 23 patients with PH, diagnosed as idiopathic (n = 15), chronic thromboembolic (n = 4), and associated with collagen vascular disease (n = 4), receiving combination vasodilator therapy at our institution. RESULTS: Vasodilator therapy before combination therapy consisted of inhaled iloprost (I; n = 12), or oral bosentan (B; n = 6) at a mean duration of 19 +/- 3 months. The combination therapy added was B (n = 8), sildenafil (S; n = 6) or I (n = 4) and in five patients, combination therapy was given from the beginning (3x BS, 1x IS, 1x IBS). Under combination therapy, the 6-minute walk distance (6MWD) increased significantly by 46.7 +/- 24.8 m (p = 0.02) after three months, and after six months it was still 38.3 +/- 28.3 m (p = 0.17) longer than before combination therapy. Respective changes in the Borg Scale and the NYHA functional class were -1.05 +/- 0.49 (p = 0.014) and -0.42 +/- 0.19 (p = 0.02) after three months and -0.21 +/- 0.65 (p = 0.61) and -0.38 +/- 0.29 (p = 0.26) after six months. Only minor side effects were reported. CONCLUSION: Combination vasodilator therapy in severe PH is safe and well tolerated. It significantly improves exercise capacity and stabilises the functional class in patients with severe PH deteriorating under single-agent therapy.

Administration, Inhalation↗
PubMed2007

Effective inhaled drug administration to mechanically ventilated patients.

Inhaled therapy is commonly employed in mechanically ventilated patients with chronic obstructive pulmonary disease or asthma. The efficacy of inhaled drugs is comparable to that achieved with systemic routes of administration, but the dose of drug required to achieve a therapeutic effect is generally much smaller. Moreover, limited systemic absorption of inhaled drugs minimises systemic side effects. Aerosol administration to ventilated patients differs from that in ambulatory patients in several respects. Optimal techniques for using pressurised metered-dose inhalers and nebulisers in ventilator circuits have been developed. With these techniques, the efficiency of inhaled drug delivery in mechanically ventilated patients is now comparable to that in ambulatory patients. Pressurised metered-dose inhalers are chiefly used to deliver bronchodilator and corticosteroid aerosols, and are more efficient and convenient to use than nebulisers for routine therapy in ventilated patients. However, nebulisers are more versatile and are employed to generate aerosols of bronchodilators, corticosteroids, antibiotics, prostaglandins, surfactant and mucolytic agents. Improvements in drug formulations and the design and efficiency of aerosol generating devices have led to increasing application of inhaled therapies in mechanically ventilated patients.

Administration, Inhalation↗
PubMed2000

[Immunohistochemical analysis of bronchial mucosa in severe asthmatics treated with long-term, high-dose inhaled BDP].

To analyze specific mucosal changes in asthmatic patients receiving long-term, high-dose beclomethazone dipropionate (BDP) inhalation therapy, we performed bronchial mucosal biopsies and immunohistochemical analysis of patients who had been treated with or without BDP-inhalation. Our study enrolled 6 chronic severe asthmatics who were treated with 1,800 micrograms/day or more of BDP with regular use for more than 3 years (HD-BDP group), 6 mild asthmatics who were not treated with BDP (non-BDP group), and 6 control subjects. Specimens of bronchial mucosa were stained with anti-EG 2 (eosinophils), anti-UCHLA-1 (T lymphocytes) and anti-tryptase (mast cells). Although limited eosinophil infiltration was observed in the HD-BDP and control groups, a significant increase was noted in the non-BDP group. The infiltration of both T lymphocytes and mast cells exhibited a statistically significant increase in the non-BDP group compared to the HD-BDP and control groups. In chronic severe asthmatics, airway mucosal cell infiltration was reduced by high-dose and long-term inhaled BDP therapy, and BDP also relieved their asthmatic symptoms. However, in mild asthmatics, bronchial mucosal cell infiltration remained high. For such patients, we concluded that initiating BDP therapy from an early stage may bring clinical improvement and help prevent cell infiltration.

Administration, Inhalation↗
PubMed1996

Does quality of care affect rates of hospitalization for childhood asthma?

BACKGROUND: Hospitalization rates for childhood asthma are three times as high in Boston, Massachusetts, as in Rochester, New York; New Haven, Connecticut, rates are intermediate. We undertook this study to determine how care for children admitted for asthma varies across these communities. METHODS: We performed a community-wide retrospective chart review. We reviewed a random sample of all asthma hospitalizations, from 1988 to 1990, of children 2 to 12 years old living in these communities (n = 614). Abstracted data included demographics, illness severity, and treatment before admission. RESULTS: Compared with Rochester children, Boston children were less likely to have received maintenance preventive therapy (inhaled corticosteroids or cromolyn [odds ratio (OR), 0.4 (0.2, 0.9)]), acute "rescue" therapy (oral corticosteroids [OR, 0.2 (0.1, 0.4)]), or inhaled beta-agonist therapy [OR, 0.5 (0.3, 1.0)]. A larger proportion of admitted asthmatic patients in Boston (34%) were in the least severely ill group-oxygen saturation 95% or above-compared with patients in Rochester (20%). CONCLUSIONS: The quality of ambulatory care, including choice of preventive therapies and thresholds for admission, likely plays a key role in determining community hospitalization rates for chronic conditions such as childhood asthma.

Acute Disease↗
PubMed1997

Dose response to inhaled nitric oxide in pediatric patients with pulmonary hypertension and acute respiratory distress syndrome.

OBJECTIVE: To determine the pulmonary vascular functional dose response to inhaled nitric oxide (NO) for infants and children with acute respiratory distress syndrome and pulmonary artery hypertension. DESIGN: Prospective, clinical observational study. SETTING: Thirteen-bed pediatric intensive care unit at a 168-bed children's hospital. PATIENTS: Infants and children requiring mechanical ventilation with an oxygenation index greater than 10. METHODS: Children with severe acute respiratory distress syndrome received inhalation therapy with NO after conventional mechanical ventilation failed to result in improvement. Inhaled NO was sequentially titrated from 10 parts per million to 20, 40, 60, and 80 ppm at 10-minute intervals. A reduction of at least 30% in the pulmonary vascular resistance index (PVRI), or a reduction in mean pulmonary artery pressure of at least 10%, or an increase in the hypoxemia score of at least 20%, or a decrease in the oxygenation index of at least 20% from pretreatment values was considered a therapeutic response. After sequential titration, children who responded received continuous inhaled NO at the lowest dose associated with a therapeutic response. RESULTS: Fourteen children received 15 trials with inhaled NO (median age, 63.4 months; range, 0.4 to 201 months). One patient's condition deteriorated during the titration phase, unrelated to NO treatment, and the patient was withdrawn from the study protocol. The mean (+/- SD) pretreatment oxygenation index was 35 +/- 15, which decreased to 32 +/- 20 at 80 ppm of inhaled NO (p = 0.01). Ten children had pulmonary artery catheter measurements. The PVRI decreased by 30% or greater in seven children (70%). One child had a minimal decrease in PVRI during the titration phase but demonstrated an increase of more than 30% after NO therapy was discontinued. Mean pretreatment PVRI (270 +/- 106) decreased to 207 +/- 92 dynes/sec per cubic centimeter per square meter at 80 ppm of inhaled NO (p = 0.06). Pretreatment mean pulmonary artery pressure (31 +/- 7) decreased to 28 +/- 5 mm Hg at 80 ppm of inhaled NO (p = 0.04). Six trials (43%) showed an increase of 20% or greater in their hypoxemia score. Maximum improvement in the hypoxemia score and reduction in OI, PVRI, and mean pulmonary artery pressure occurred at 20 to 40 ppm of NO. Ten trials led to continuous inhaled NO therapy ranging from 7 to 661.5 hours, with a median of 47 hours. Systemic hypotension was not observed in any patient, and the maximum methemoglobin level was 5%. CONCLUSION: Inhaled NO appears to be a safe, although variably effective, therapy for the treatment of infants and children with acute respiratory distress syndrome. The maximum dose response occurs between 20 and 40 ppm of inhaled NO. Systemic side effects did not occur in any child who received NO therapy.

Administration, Inhalation↗
PubMed1986

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

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.

Adolescent↗