Use Of Metered-dose Inhalers Research Articles

Measuring the Quality of Inpatient Care for Asthma

Hospital Care| March 01 2009 Measuring the Quality of Inpatient Care for Asthma AAP Grand Rounds (2009) 21 (3): 30. https://doi.org/10.1542/gr.21-3-30 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Measuring the Quality of Inpatient Care for Asthma. AAP Grand Rounds March 2009; 21 (3): 30. https://doi.org/10.1542/gr.21-3-30 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search toolbar search search input Search input auto suggest filter your search All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: asthma, inpatients Source: Nkoy FL, Fassl BA, Simon TD, et al. Quality of care for children hospitalized with asthma. Pediatrics. 2008;122(5):1055–1063; doi:10.1542/peds.2007–2399 In this retrospective, observational study researchers from Primary Children’s Medical Center in Salt Lake City developed evidence-based measures of quality for the inpatient management of asthma, and evaluated rates of compliance with these measures at their institution. Utilizing systematic methodologies to review the literature and develop expert consensus, the research team identified 43 potential measures of quality. Of these, a consensus panel selected nine final measures that were evidence-based, feasible, and could be reliably assessed using chart review. The nine final quality measures evaluated specific medical decisions or attributes of the processes of care for asthma in the hospital. Clinical outcomes were not measured directly, but were assumed to be linked to the quality measures based on support from the medical literature. Compliance with the identified measures was rated utilizing retrospective chart review of children 2–17 years of age discharged from the hospital with a primary diagnosis of asthma exacerbation during 2005. The medical records of 252 patients were reviewed. Provider compliance with quality measures specific to acute inpatient management of asthma included: documentation of asthma severity at admission, 39%; use of systemic corticosteroid therapy, 98%; use of oral, not intravenous, corticosteroid, 87%; use of ipratropium bromide limited to the first 24 hours after admission, 71%; and use of metered-dose inhaler rather than nebulizer for children >5 years of age, 20%. Provider compliance with these measures was higher than compliance with the four measures related to preventing re-exacerbation and readmission: documentation of chronic asthma severity, 22%; parental participation in asthma education class, 33%; provision of a written asthma action plan, 5%; and scheduled follow-up with the primary care provider at discharge, 22%. This research team identified nine potential determinants of quality of care for children hospitalized with asthma. Variable and low compliance with these measures suggests that emphasizing and monitoring these measures may lead to improvements in the quality of inpatient care for these patients. Dr. Pate has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device. This study has important limitations, many of which are discussed comprehensively by the authors. Two deserve special attention. First, the study may have been subject to bias in the selection of patients, the selection of final quality measures, and the description of institutional compliance with the measures. Second, due to the chart review methodology, several important indicators of quality of asthma care were not included in the group of final measures. Taken together, these limitations weaken the implied association between the nine measures and overall quality of clinical outcomes in asthma care for hospitalized patients. Measuring specific medical decisions, documentation, and processes as determinants of quality is attractive because these endpoints may be easier to measure than clinical outcomes. However, in order to maximize the value of this intermediate focus, we must demonstrate a... You do not currently have access to this content.

Does It Really Matter What Volume to Exhale Before Using Asthma Inhalation Devices?

Correct use of inhalation devices is one essential component of optimal management of asthma. Several longstanding controversies regarding specific steps to correct use of metered dose inhalers (MDI) include the lung volume when the MDI should be actuated. As a primary objective, literature was reviewed examining this one step in MDI use. Results from six of nine investigations support the need to gently exhale either to functional residual capacity (FRC) or residual volume (RV) before MDI actuation. Literature is also summarized regarding the need to exhale to FRC or RV before inhaling from MDI plus valved holding chambers or other extension devices and from dry powder inhalers. Numerous studies indicate that many patients as well as health care professionals either do not know or forget to exhale to RV or FRC before inhaling asthma medications. Both patients and health care professionals need education to help ensure correct use of MDI and other asthma inhalation devices, including instruction to first exhale gently to RV or FRC before inhaling the medication.

Effect of hydrofluoroalkane–ethanol inhalers on estimated alcohol levels in asthmatic subjects

Inhaled medication administered via a metered dose inhaler (MDI) is often used to treat asthma. Hydrofluoroalkane (HFA) has replaced chlorofluorocarbons (CFC) as the propellant and these new MDI may contain alcohol. This raises concerns that their use may transiently increase breath ethanol concentration (BEC), thereby interfering with random breath testing. It was hypothesized that HFA-ethanol MDI may contribute to raising BEC above the legal limit. The effect of a HFA-ethanol MDI on BEC was compared with that of CFC and placebo MDI and the effect of ingesting a standard amount of alcohol was also investigated. Asthmatic (n = 16) and normal control subjects (n = 15) were recruited for the double-blind, placebo-controlled study. Each subject used the three MDI in random sequence. BEC was measured at baseline and at 2, 5 and 15 min after inhalation of each MDI, using the Lion Alcometer SD-400TM. Spirometry was performed at baseline and 20 min after the last inhalation. An identical procedure was followed after alcohol consumption. Use of the HFA-ethanol MDI resulted in a significant increase in BEC from 0.002 to 0.0138 mg/100 mL (28 mg/100 mL of blood, P = 0.001) in asthmatics, and from 0.001 mg/100 mL to 0.016 mg/100 mL (33 mg/100 mL of blood, P = 0.002) in normal subjects. By 5 min, there were no significant differences in BEC of asthmatics (0.0031 mg/100 mL) and normal subjects (0.003 mg/100 mL), when compared with baseline (P > 0.2). BEC are transiently elevated after inhalation of HFA-ethanol MDI; however, by 5 min, BEC had already returned to baseline levels. Thus the effect of HFA-ethanol MDI on BEC is transient and would be negligible after 5 min.

Relationship between recent short-acting β-agonist use and subsequent asthma exacerbations

US national guidelines recommend assessing short-acting beta-agonist (SABA) medication use as a marker of asthma severity and control. However, the relationship between recent SABA use and asthma exacerbations is not currently known. To evaluate the proximal relationship between the type and frequency of SABA use and asthma-related outcomes. We evaluated SABA use among patients with asthma ages 5 to 56 years who were members of a large health maintenance organization in southeast Michigan. Frequency of use was estimated from pharmacy data assessing the timing and amount of SABA fills. Cox proportional hazards models were used to examine the prospective relationship between average daily SABA use for 3 months and outcomes associated with poor asthma control (ie, oral corticosteroids use, asthma-related emergency department visits, and asthma-related hospitalizations). We separately accounted for SABA metered-dose inhaler (MDI) and SABA nebulizer use. Of the 2,056 patients who met study criteria, 1,569 (76.3%) had used a SABA medication in their baseline year. After adjusting for potential confounders, SABA nebulizer use was associated with asthma-related emergency department visits (adjusted hazard ratio [aHR], 6.32; 95% confidence interval [CI], 2.38 to 16.80) and asthma-related hospitalizations (aHR, 21.62; 95% CI, 3.17 to 147.57). In contrast, frequency of SABA MDI use was not associated with these outcomes. Frequency of SABA use during a 3-month period was associated with poor asthma outcomes. The relationship with poor asthma outcomes was strongest for SABA nebulizer use, suggesting that the type of SABA used is also of prognostic importance.

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

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. 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. 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. 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. 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. 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). 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.

Avaliação do conhecimento sobre o uso de inaladores dosimetrados entre profissionais de saúde de um hospital pediátrico

To evaluate health professionals working at a tertiary pediatric hospital in terms of their knowledge regarding the practical use of metered-dose inhalers. Practical and written tests on the use of metered-dose inhalers were applied to physicians, physical therapists, nurses and nursing assistants. A score from 0 to 10 was assigned to each evaluation, and median scores were calculated for each professional category. Questions with higher and lower correct values were identified, and a descriptive comparison was made regarding the performance of the various professional categories. Statistical analysis was performed using the Kruskal-Wallis method for comparison of medians. A sequential logistic multiple regression analysis was also performed. A total of 30 resident physicians or interns in the pediatrics department, 23 attending physicians, 29 physical therapists, 33 nurses and 31 nursing assistants were evaluated. Resident physicians, physical therapists and attending physicians performed significantly better than did nurses and nursing assistants. Only resident physicians had a median score greater than 6. The health professionals evaluated, particularly the nurses and nursing assistants, who are directly involved in the practical use of metered-dose inhalers, possess insufficient knowledge regarding the use of such inhalers.

Validation of a Questionnaire for Assessing Adherence to Metered-Dose Inhaler Use in Asthmatic Children

Maintenance therapies for asthma are vulnerable to low adherence. Clinicians would benefit from having a validated questionnaire to assess adherence to metered-dose inhaler use in children with asthma. The objective of this study was to design and validate a questionnaire assessing adherence to metered-dose inhaler use, to be filled out by the parents and/or caregivers of children with asthma. The six questions on the Pediatric Inhaler Adherence Questionnaire were obtained from reviewing the literature, from carrying out focus group discussions, and from the researchers' professional experience. We assessed concurrent criterion validity using canister weight change as the gold standard and also assessed test–retest reliability. The questionnaire was administered to the parents/caregivers of 64 children aged 3.6 ± 2.2 years. Questionnaire scores correlated positively with the absolute value of the difference between 100 and percent taken of prescribed (Spearman correlation coefficient rho = 0.42, p = 0.001). The sensitivity of the questionnaire in detecting nonadherent patients ranged from 50% to 75%; positive predictive value ranged from 23.1% to 66.7%; and likelihood ratio ranged from 1.5 to 5.5 for the detection of nonadherent patients. The Pediatric Inhaler Adherence Questionnaire is a valid, reliable, quick, inexpensive, and easy-to-use instrument that allows quantitative assessment of metered-dose inhaler adherence in children with asthma, and may be useful across a range of clinical and research settings.

Long-term safety study of levalbuterol administered via metered-dose inhaler in patients with asthma

Previous studies have raised concerns regarding the safety of regular use of beta2-agonists for treating asthma. Few studies have explored the safety of at least 1 year of use of racemic albuterol, and none have examined long-term dosing of levalbuterol. To examine the long-term safety of levalbuterol hydrofluoroalkane (HFA) vs racemic albuterol HFA administered via metered-dose inhaler (MDI) in patients with stable asthma. Patients with mild to moderate asthma (mean forced expiratory volume in 1 second [FEVI], 68.3% of predicted) 12 years or older participated in a multicenter, parallel-group, open-label study. Patients were randomized to levalbuterol HFA MDI (90 microg; 2 actuations of 45 microg; n = 496) or racemic albuterol HFA MDI (180 microg; 2 actuations of 90 microg; n = 250) for 52 weeks of 4 times daily dosing. The primary end point was the incidence of postrandomization adverse events. Asthma exacerbations and pulmonary parameters were also assessed. The overall incidence of adverse events was similar for levalbuterol (72.0%) and racemic albuterol (76.8%). Rates of beta-mediated adverse events, serious adverse events, and discontinuations because of adverse events were low (<15%) and were comparable between groups. Rates of asthma adverse events for levalbuterol and racemic albuterol were 18.3% and 19.6%, respectively. Mean percentage of predicted FEV1 improved after dosing and was stable for both groups. In this trial, up to 52 weeks of regular use of levalbuterol HFA MDI or racemic albuterol HFA MDI was well tolerated, and no deterioration of lung function was detected during the study period.

An Assessment of Knowledge, and Beliefs of Pediatric Emergency Nurses Towards the use of Metered-dose Inhaler and Spacer (MDI+S) for the Treatment of Acute Asthma Before and 12 Months after a Practice Change

An Assessment of Knowledge, and Beliefs of Pediatric Emergency Nurses Towards the use of Metered-dose Inhaler and Spacer (MDI+S) for the Treatment of Acute Asthma Before and 12 Months after a Practice Change

Survey of Albuterol Delivery Methods in Emergency Departments for Acute Asthma Exacerbation in Children 2 Months to 15 Years

The management of pediatric bronchial asthma is often addressed by emergency department (ED) personnel. By surveying emergency program directors, we identify prevailing methods of albuterol delivery for the treatment of an acute asthma exacerbation. Because the Cochrane systematic review reports an equivalent effectiveness of the nebulizer versus metered dose inhaler (MDI) with valved holding chambers (VHC) for albuterol delivery, one might surmise that their usage would be evenly split. However, we find that within an ED setting, use of MDI with VHC sans nebulizer for acute asthma exacerbation is seldom used: 0–1% across all age groups. This is even more surprising considering the nebulizer has been shown to be more expensive than MDI with VHC. It stands to reason the promotion of national guidelines would result in potential cost savings. (Pediatr Asthma Allergy Immunol 2006; 19[3]:180–184).

Efficacy and safety of inhaled fluticasone propionate chlorofluorocarbon in 2- to 4-year-old patients with asthma: results of a double-blind, placebo-controlled study

Current asthma guidelines recommend inhaled glucocorticoids administered via pressurized metered-dose inhaler (MDI) with a holding chamber as the preferred therapy for young children with asthma. To evaluate the efficacy and safety of fluticasone propionate chlorofluorocarbon MDI use in preschool-aged children with asthma. Randomized, double-blind, placebo-controlled, parallel-group study of 332 children aged 24 to 47 months with asthma. Fluticasone propionate chlorofluorocarbon, 44 or 88 microg twice daily, or placebo (chlorofluorocarbon propellant alone) administered for 12 weeks via MDI with a valved holding chamber and an attached face mask. The primary efficacy measure was average change in 24-hour daily asthma symptom scores. Safety assessments included adverse events, 12-hour urinary cortisol excretion, and growth. Treatment failure (ie, asthma exacerbation) occurred in approximately half as many fluticasone propionate-treated patients (13%-14%) as placebo-treated patients (24%). Compared with placebo users, patients treated with fluticasone propionate, 88 microg twice daily, had a 13% greater improvement in the mean proportion of symptom- and albuterol-free days (P = .02); asthma symptom scores and albuterol use were also significantly reduced. Patients treated with fluticasone propionate, 44 microg twice daily, had greater improvements than placebo-treated patients; however, differences did not reach statistical significance. At end point, the growth velocities of fluticasone propionate-treated patients were within the range of those of placebo-treated patients. No clinically relevant changes in 12-hour overnight urinary cortisol excretion were observed. Compared with placebo use, fluticasone propionate, 88 microg administered twice daily, significantly reduced asthma exacerbations, asthma symptoms, and rescue albuterol use and was well tolerated, with no clinically relevant systemic effects, as measured by growth velocity or 12-hour urinary cortisol excretion levels.

The role of computerized order sets in pediatric inpatient asthma treatment

Condition-specific order sets within computerized physician order entry (CPOE) systems are designed to decrease unnecessary practice variation and to promote evidence-based practice. This study quantitatively assessed the relationship between use of a computerized order set and processes of care in inpatient pediatric asthma treatment, and qualitatively assessed user attitudes toward order set use. The study population included 790 patients with a primary diagnosis of asthma admitted to Columbus Children's Hospital between November 1, 2001 and November 30, 2003. Rates of systemic corticosteroid (SCS) use, metered-dose inhaler use, and pulse oximetry (PulseOx) were calculated for three patient groups: those admitted prior to order set implementation ('pre-set'); those admitted after implementation but without the order set used ('no set'); and those admitted after implementation with the order set used ('set'). Financial measures of length of stay, total charges, and pharmacy charges were also calculated. Focus groups exploring attitudes about order sets were held with physician users of order sets. Order set patients were significantly more likely to receive SCS and PulseOx than 'pre-set' and 'no set' patients. 'No set' patients did not differ significantly from 'pre-set' patients. No significant differences were found in financial measures. Results from focus groups suggested that order set use would be optimized by promoting order set awareness and maximizing order set quality. These results give further credence to policy-makers' calls for expanded use of CPOE systems with condition-specific order sets to facilitate provision of evidence-based care.

Proficiency of Pediatricians in the Use of Inhaled Medication Delivery Systems for the Management of Asthma

Objective: To evaluate the proficiency of pediatricians in the demonstration of the proper use of metered-dose inhalers (MDIs) and to assess their theoretical knowledge of inhalation devices used in the management of asthma. Design: Prospective cross-sectional survey. Setting: Two university-affiliated hospitals. Participants: Seventy-one pediatricians and pediatric house staff. Intervention: Each pediatrician's technique was graded by two trained observers using a checklist of six essential steps recommended by national guidelines. Theoretical knowledge of asthma devices was evaluated by a written questionnaire. Results: Twenty (35.2%) pediatricians performed at least five steps correctly, 28 (39.4%) performed three or four steps correctly, and 18 (25.4%) performed two steps or less correctly. The most common errors were failure to start inhalation from functional residual capacity, failure to inhale slowly, and failure to wait at least 20 seconds before the next puff. Senior pediatricians were more skillful in the practical use of MDIs than were pediatric house staff (p = 0.03). The most common deficiencies in theoretical knowledge were related to estimation of the amount of medication in the canister (8.5% correct) and how valved holding chambers (VHCs) improve drug delivery to the lung (15.5% correct). Conclusion: Pediatricians in Kuwait have significant deficiencies regarding the practical and theoretical aspects of MDIs and other inhalation devices.

A Comparison of Standard Inhalers for Asthma With and Without Alcohol as the Propellant on the Measurement of Alcohol in Breath

Because most bronchodilator inhalers contain propellant gases or a small amount of ethanol as a co-solvent, the potential for these products to generate false readings on a evidential breath alcohol instrument was evaluated in 69 volunteers with clinically stable asthma. All subjects underwent a breath test on an infrared breath alcohol analyzer (Alcotest 7110, Dräger, Lübeck, Germany) before the use of the asthma inhaler and 1 and 5 min after inhalation. The effects of antiasthmatic medications delivered by metered dose inhalers (MDIs) with alcohol as a vehicle, alcohol-free MDIs, and dry powder inhalers were assessed in homogeneous groups of four to five patients. All subjects were alcohol-free on the preliminary breath test. One minute after inhalation, negative readings were only observed in 25 (36.2%) of subjects. In 62.3% of patients, apparent alcohol results were considered interferences or unstable readings by the breath-test instrument. One subject showed a final positive breath alcohol level (0.07 mg/L). After the use of dry powder inhalers, valid results without interferences were obtained. However, 89.6% of patients in which bronchodilators were delivered by MDIs (with propellant gases in the aerosol) showed altered partial readings and labeled the final output as "invalid," but tests performed 5 min after the use of inhalers were valid and correct in all cases. MDIs with propellants as a vehicle may cause false positive breath alcohol readings in some patients. These effects are transient and may be prevented by a 5-10-min interval between the use of MDIs and breath alcohol testing.

An indigenous spacer device for drug delivery in severely dyspnoeic patients

Bronchodilator aerosols are commonly delivered through nebulizers or metered dose inhalers (MDI) to treat bronchospasm. Although the clinical results obtained with both these devices are comparable, the use of MDI offers several advantages like lower drug dose, reduced risk of complications, reliability of dosing, ease of administration, less personnel time and reduced cost. However, in non-intubated, spontaneously breathing patients, the amount of drug inhaled depends on the coordination of the inspiratory phase and delivery of the drug. In severely dyspnoeic or disoriented patients in the casualty department or intensive care settings, this is often not possible. Valved spacers and breath-actuated inhalers may not be easily available in such situations. Also, the spacer devices cannot be connected to the anatomical facemask and the need to discontinue oxygenation for aerosol delivery further limits their use.

A Study of Patient Responses to a Perceived Change in Salbutamol Metered Dose Inhalers

Experience in the clinic reveals that some patients have attributed negative changes in their respiratory health status to generic substitution of inhaled medications, even though — from a pharmacological perspective — therapeutic equivalence would be expected. The objective of this study was to evaluate patient-reported changes in efficacy or toxicity following a perceived switch of an inhaled drug product. Forty-eight patients with air flow limitation had their usual brand of salbutamol metered-dose inhaler (MDI) replaced for one week with a new MDI. Patients were not informed that the replacement MDI was exactly the same brand as their usual MDI, and the product identity was disguised by a label. Forced expiratory volume in one second, respiratory symptoms and MDI use were compared between the week when the patients knew they were using their usual brand of MDI and the week they were using the perceived new MDI. Patient MDI preference was assessed at the end of the study. Even though there was no change in the brand of salbutamol MDI, 46 per cent of patients thought that the new MDI was better at managing their symptoms, 27 per cent thought that the new MDI was worse and 27 per cent perceived no difference (p&lt;0.05 for rejecting the null hypothesis that all responses would be for no difference). Seventy per cent of patients stated that they had a preference for one MDI over the other, even though there had been no change in inhaler. Factors other than product differences are likely to be responsible for patient claims of changes in respiratory health status subsequent to generics substitution with inhaled medications when equivalent products are used. If such changes are reported following the introduction of a new generic product, the changes may be incorrectly attributed to the new product, confounding the ability to assess the quality of the new product in post-marketing evaluation.

Systemic and pulmonary effects of fluticasone administered through a metered-dose inhaler in rats

Metered-dose inhalers (MDIs) are convenient, simple, inexpensive, and reproducible devices for administering aerosolized drugs through the pulmonary route, but methods have not been available for use of these devices in small animals. We sought to test the efficacy of delivery of fluticasone through an MDI to rats with a rodent-adapted spacer chamber and to compare this treatment with systemic dexamethasone for the acute pulmonary allergic inflammatory response. Changes in body and thymus weights were used as indicators for systemic steroid effects. Rats were sensitized to ragweed pollen extract 2 weeks before the experiment, and pulmonary allergic responses were evaluated 48 hours after a single aerosolized antigen challenge on the basis of bronchoalveolar leukocytes, lung tissue sections, total lung capacity, and forced expiratory volumes. Inhaled fluticasone caused dose-related systemic effects, indicating successful pulmonary drug delivery. Inhaled fluticasone was more effective than placebo but less effective than systemic dexamethasone in attenuating the increase in lung eosinophils and inflammatory infiltrates and the decrease in total lung capacity associated with the allergic inflammatory response. Inhaled fluticasone prevented airway obstruction and proximal inflammation, as did dexamethasone, but it appeared to have less effect in areas of lung served by the most distal airways. This is an effective method for use of MDIs to deliver inhaled drugs to small laboratory animals, and it should be valuable for investigations of treatment effects, as well as for in vivo testing of delivery devices.

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

Delgado A, Chou KJ, Silver EJ, et al (Albert Einstein College of Medicine, Bronx, NY) The introduction of spacer devices for metered-dose inhalers (MDIs) has aided in the treatment of wheezing in infants and young children brought to the emergency department (ED). In a randomized, double-blind trial, albuterol administered by an MDI with a spacer was compared for efficacy with nebulizer-administered albuterol for the ED treatment of wheezing infants and children aged 2 to 24 months. The study population consisted of a convenience sample of infants and young children seen between August 1995 and December 1996. Exclusion criteria included chronic lung conditions other than asthma, a history of congenital heart disease, and signs of impending respiratory failure. Patients in the nebulizer group received a placebo MDI with a spacer followed by nebulized albuterol. The spacer group received albuterol by an MDI with a spacer followed by nebulized isotonic sodium chloride solution. Admission rate was the primary outcome. A total of 168 patients were enrolled (85 in the nebulizer group and 83 in the spacer group). The 2 groups were similar in demographic characteristics and baseline clinical findings, except that the nebulizer group had a significantly higher mean pulmonary index (PI) score. Patients in the spacer group had a significantly lower admission rate (5% versus 20% in the nebulizer group), received fewer treatments, had a lower mean increase in heart rate, and were less likely to receive steroids. The admission rate remained lower in the spacer group after controlling for initial PI scores. Lower admission rates in the spacer group were found primarily in children with a more severe asthma exacerbation. Acute wheezing episodes bring many infants and young children to the ED, and their treatment often requires considerable time and resources. The use of MDIs with spacers offers an easier, more efficient, and cost-effective way of delivering albuterol in such cases. Compared with nebulizers, MDIs with spacers are associated with a lower admission rate and a reduced increase in heart rate.

Effect of the combination of two bronchodilators on breathlessness in patients with chronic obstructive pulmonary disease. A crossover clinical trial

Background. Dyspnea is the major limiting symptom for patients with chronic obstructive pulmonary disease (COPD). This study was designed to investigate the impact of the combination of two bronchodilators on perception of dyspnea in these patients. Methods. Twenty patients with moderate to severe COPD (age was [mean±standard deviation (SD)] 64±7 years, FEV 1/FVC ratio was 45±11%) were randomized in a crossover, double-blind, placebo-controlled clinical trial to receive two puffs of either ipratropium bromide plus salbutamol (IB + S), IB + placebo (P), S + P, or P + P through metered dose inhalers (MDIs) daily over a 2-week period for each combination. At the end of each period, spirometry was obtained at baseline and 15, 30, 60, and 120 min after bronchodilator. Dyspnea was evaluated using a Borg scale during a 12-min walking test (12-MWT) performed at baseline and 120 min after MDIs use. In addition, the dyspnea component of the Chronic Respiratory Disease Questionnaire (CRDQ) and a diary of symptoms were used to evaluate this symptom. Results. After 15 days of treatment, FEV 1 improved significantly with all three combinations of MDIs containing bronchodilator agents. In comparison with placebo, significant improvement in dyspnea during 12-MWT was observed only when the combination of IB + S was used. No significant changes in CRDQ or patients' symptom diaries were observed with any combinations used. Conclusions. Combination of the two bronchodilators used in this study appears to alleviate perception of dyspnea more than use of either agent alone.

Patient perceptions of an inhaled asthma medication administered as an inhalation powder via the Diskus or as an inhalation aerosol via a metered-dose inhaler

To evaluate patient preference, ease of use, and correctness of use of fluticasone propionate administered as inhalation powder via the Diskus (GlaxoSmithKline, Research Triangle Park, NC) and as inhalation aerosol administered via metered-dose inhaler (MDI). In 154 patients 12 years of age and older with asthma and a history of MDI use, the Diskus and the MDI were compared in a randomized, open-label, 7-week crossover study. In patients who had used both devices, more found the Diskus easier to use (59%) and preferred it overall (60%) compared with the MDI (P < or = 0.025). Ninety-eight percent (for the MDI) vs 91% (for the Diskus) of patients were able to correctly perform all the maneuvers necessary to use the devices correctly by either viewing a single demonstration and/or reading the instructions for use. Ninety-four percent of all patients found it easier to tell the number of residual doses with the Diskus (P < 0.001), and 59% of patients indicated that they would most likely request the Diskus from their physician (P = 0.025). Compliance was significantly better with the Diskus; 91.1% of patients used the Diskus as directed compared with 78.6% for the MDI (P = 0.013). In patients exposed to both devices, the majority preferred the Diskus and found it easier to use compared with the MDI. Ninety-one percent of patients used the Diskus correctly with minimal training, and when given a choice, most indicated they would likely request the Diskus from their physicians. Together, these data indicate a significant level of acceptance of the Diskus device in this patient population.