Salmeterol administration by metered-dose inhaler alone vs metered-dose inhaler plus valved holding chamber

A review of the in vitro and in vivo valved holding chamber (VHC) literature with a focus on the AeroChamber Plus Flow-Vu Anti-static VHC

Valved holding chambers (VHCs) reduce the need for inhalation-actuation coordination with pressurized metered dose inhalers (pMDIs), reduce oropharyngeal drug deposition and may improve lung deposition and clinical outcomes compared to pMDIs used alone. While VHCs are thus widely advocated for use in vulnerable patient groups within clinical and regulatory guidelines, there is less consensus as to whether the performance differences between different VHCs have clinical implications. This review evaluates the VHC literature, in particular the data pertaining to large- versus small-volume chambers, aerosol performance with a VHC adjunct versus a pMDI alone, charge dissipative/conducting versus non-conducting VHCs, and facemasks, to ascertain whether potentially meaningful differences between VHCs exist. Inconsistencies in the literature are examined and explained, and relationships between in vitro and in vivo data are discussed. A particular focus of this review is the AeroChamber Plus® Flow-Vu® Anti-static VHC, the most recent iteration of the AeroChamber VHC family.

Metered-dose inhaler for asthma patients: knowledge and effects of a theoretical and practical guidance for pediatricians

OBJECTIVE

To evaluate the effect of a theoretical and practical guidance on knowledge of pediatricians regarding the use of metered dose inhalers with spacers. To identify major deficiencies, correct them and train these physicians on the correct use of the devices.

METHODS

Pediatricians who participated in a theoretical-practical program focusing on the use of inhaler devices answered a questionnaire with five questions about the use of these devices before and after the program. A comparison of the scores obtained in the pre- and post-training tests was performed by Wilcoxon test for related samples, and a significance level of 0.05 was adopted.

RESULTS

Twenty pediatricians performed pre- and post-training tests. The performance of pediatricians in the post-training test was significantly better than baseline (p<0.001).

CONCLUSION

A brief orientation program for pediatricians significantly improved their knowledge on the use of metered-dose inhalers with spacers, which may translate into an improvement in quality and quantity of prescriptions of these devices in clinical practice. The questions with higher rates of errors in the pre-training test were the questions about the waiting time between two sprays in successive applications and about the correct way to attach the inhaler to the spacer, both with high levels of success in the post-training test.

A Rationale for Going Back to the Future: Use of Disposable Spacers for Pressurised Metered Dose Inhalers

The introduction of pressurised metered dose inhalers (MDIs) in the mid-1950s completely transformed respiratory treatment. Despite decades of availability and healthcare support and development of teaching aids and devices to promote better use, poor pMDI user technique remains a persistent issue. The main pMDI user aid is the spacer/valved holding chamber (VHC) device. Spacer/chamber features (size, shape, configuration, construction material, and hygiene considerations) can vie with clinical effectiveness (to deliver the same dose as a correctly used pMDI), user convenience, cost, and accessibility. Unsurprisingly, improvised, low-cost alternatives (plastic drink bottles, paper cups, and paper towel rolls) have been pressed into seemingly effective service. A UK law change permitting schools to hold emergency inhalers and spacers has prompted a development project to design a low-cost, user-friendly, disposable, and recyclable spacer. This paper spacer requires neither preuse priming nor washing, and has demonstrated reproducible lung delivery of salbutamol sulphate pMDI, comparable to an industry-standard VHC, an alternative paperboard VHC, and pMDI alone. This new device appears to perform better than these other VHC devices at the low flow rates thought achievable by paediatric patients. The data suggest that this disposable spacer may have a place in the single-use emergency setting.

Potential of a cyclone prototype spacer to improve in vitro dry powder delivery

Purpose

Low inspiratory force in patients with lung disease is associated with poor deagglomeration and high throat deposition when using dry powder inhalers (DPIs). The potential of two reverse flow cyclone prototypes as spacers for commercial carrier-based DPIs was investigated.

Methods

Cyclohaler®, Accuhaler® and Easyhaler® were tested with and without the spacers between 30 and 60 Lmin⁻¹. Deposition of particles in the next generation impactor and within the devices was determined by high performance liquid chromatography.

Results

Reduced induction port deposition of the emitted particles from the cyclones was observed due to the high retention of the drug within the spacers (e.g. salbutamol sulphate (SS): 67.89 ± 6.51% at 30 Lmin⁻¹ in Cheng 1). Fine particle fractions of aerosol as emitted from the cyclones were substantially higher than the DPIs alone. Moreover, the aerodynamic diameters of particles emitted from the cyclones were halved compared to the DPIs alone (e.g. SS from the Cyclohaler® at 4 kPa: 1.08 ± 0.05 μm vs. 3.00 ± 0.12 μm, with and without Cheng 2, respectively) and unaltered with increased flow rates.

Conclusion

This work has shown the potential of employing a cyclone spacer for commercial carrier-based DPIs to improve inhaled drug delivery.

Evaluation of asthma control, parents' quality of life and preference between AeroChamber Plus and AeroChamber Plus Flow-Vu spacers in young children with asthma

OBJECTIVE

The AeroChamber Plus (AC) valved holding chamber has been enhanced to include the Flow-Vu (FV) inspiratory flow indicator that provides visual inhalation feedback during use. We have investigated if FV alters asthma control and whether parents accept it.

METHODS

At visit 1, children with asthma, age 1-5 years, used an AC with their pressurised metered dose inhaler and 2 weeks later (visit 2) they were randomised to use either AC or FV. Subjects returned 6 (visit 3) and 12 (visit 4) weeks later. The Asthma Control (ACQ) and Paediatric Asthma Caregiver's Quality of Life (PACQLQ) questionnaires were scored at each visit, and their peak inhalation flow (PIF) when they used their spacer was measured.

RESULTS

Forty participants in each group completed the study. There was no difference in the ACQ scores from visits 2 to 4 between the two groups. The improvements in the PACQLQ scores were greater in the FV group (p = 0.029). The mean difference (95% confidence interval) for the change from visits 2 to 4 between FV and AC groups was 0.05 (-0.33, 0.43) and 0.39 (0.035, 0.737) for the ACQ and PACQLQ, respectively. Most parents preferred the FV (p < 0.001). There was no difference in the PIF rates at each visit and between the two spacers.

CONCLUSIONS

There was no change in asthma control of the young children but that of their parents improved. Parents preferred the FV and this could be related to their improved perception of their children's asthma control by better PACQLQ scores.

Epidemiology and management of common pulmonary diseases in older persons

Pulmonary disease prevalence increases with age and contributes to morbidity and mortality in older patients. Dyspnea in older patients is often ascribed to multiple etiologies such as medical comorbidities and deconditioning. Common pulmonary disorders are frequently overlooked as contributors to dyspnea in older patients. In addition to negative impacts on morbidity and mortality, quality of life is reduced in older patients with uncontrolled, undertreated pulmonary symptoms. The purpose of this review is to discuss the epidemiology of common pulmonary diseases, namely pneumonia, chronic obstructive pulmonary disease, asthma, lung cancer, and idiopathic pulmonary fibrosis in older patients. We will review common clinical presentations for these diseases and highlight differences between younger and older patients. We will also briefly discuss risk factors, treatment, and mortality associated with these diseases. Finally, we will address the relationship between comorbidities, pulmonary symptoms, and quality of life in older patients with pulmonary diseases.

A novel breath-actuated integrated vortex spacer device increases relative lung bioavailability of fluticasone/salmeterol in combination

BACKGROUND

Spacer devices facilitate respirable drug delivery. A novel breath-actuated antistatic spacer with integrated vortex chamber (Synchro-Breathe) device has been developed, which is compact,portable and user friendly as compared to conventional spacers which are bulky and cumbersome. The relative bioavailability to the lung of inhaled fluticasone and salmeterol combination is primarily dependent on respirable dose delivery and can be reliably quantified using adrenal suppression and early fall in serum potassium (marker of systemic beta-2 adrenoreceptor response) as surrogate markers for delivered lung dose.

AIMS AND OBJECTIVES

To compare the in vivo relative bioavailability to the lung of Hydrofluoroalkane(HFA) Seretide delivered via Synchro-Breathe (SB); an optimally prepared 750 ml large volume plastic spacer, Volumatic (VM); and conventional Evohaler pMDI (EH).

METHODS

Nineteen healthy volunteers completed the study using a randomised double blind, double dummy crossover design. Single doses of placebo or Seretide HFA 250 (total dose ex-valve: fluticasone 2000 mcg/salmeterol 200 mcg) were administered via SB, VM and EH. Overnight urinary cortisol creatinine (OUCC) and serum potassium (K) were measured at baseline and after each dose as systemic surrogates of relative respirable dose delivery for the fluticasone and salmeterol moieties, respectively.

RESULTS

Significant suppression of OUCC and K occurred from baseline with SB and VM but not EH devices(geometric mean fold suppression, 95% CI, p and arithmetic mean fall mmol/L, 95% CI, respectively); EH:1.51(0.43-1.01), p 1/4 0.06; VM: 2.52(1.57-4.04), p < 0.001; SB: 2.66(1.57-4.49), p < 0.001(equating to 33.8%,60.2% and 62.3% falls, respectively). For K, the falls for EH were 0.09(0.25 to 0.07), p 1/4 0.69; VM: 0.27(0.46 to 0.08), p 1/4 0.003; SB: 0.32(0.53 to 0.11), p 1/4 0.002 (equating to 2.2%, 6.8%, and 8.06% fall,respectively). There were no significant differences between SB and VM.

CONCLUSION

The breath-actuated Synchro-Breathe device was comparable to an optimally prepared Volumatic spacer, and resulted in commensurate improvement in relative lung bioavailability for both fluticasone and salmeterol moieties compared to pMDI.

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.

Efficacy and cost comparisons of bronchodilatator administration between metered dose inhalers with disposable spacers and nebulizers for acute asthma treatment

BACKGROUND

Despite demonstration of equivalent efficacy of beta agonist delivery using a metered dose inhaler (MDI) with spacer vs. nebulizer in asthma patients, use of a nebulizer remains standard practice.

OBJECTIVES

We hypothesize that beta agonist delivery with a MDI/disposable spacer combination is an effective and low-cost alternative to nebulizer delivery for acute asthma in an inner-city population.

METHODS

This study was a prospective, randomized, double-blinded, placebo-controlled trial with 60 acute asthma adult patients in two inner-city emergency departments. Subjects (n = 60) received albuterol with either a MDI/spacer combination or nebulizer. The spacer group (n = 29) received albuterol by MDI/spacer followed by placebo nebulization. The nebulizer group (n = 29) received placebo by MDI/spacer followed by albuterol nebulization. Peak flows, symptom scores, and need for rescue bronchodilatator were monitored. Median values were compared with the Kolmogorov-Smirnov test.

RESULTS

Patients in the two randomized groups had similar baseline characteristics. The severity of asthma exacerbation, median peak flows, and symptom scores were not significantly different between the two groups. The median (interquartile range) improvement in peak flow was 120 (75-180) L/min vs. 120 (80-155) L/min in the spacer and nebulizer groups, respectively (p = 0.56). The median improvement in the symptom score was 7 (5-9) vs. 7 (4-9) in the spacer and nebulizer groups, respectively (p = 0.78). The median cost of treatment per patient was $10.11 ($10.03-$10.28) vs. $18.26 ($9.88-$22.45) in the spacer and nebulizer groups, respectively (p < 0.001).

CONCLUSION

There is no evidence of superiority of nebulizer to MDI/spacer beta agonist delivery for emergency management of acute asthma in the inner-city adult population. MDI/spacer may be a more economical alternative to nebulizer delivery.

[Evaluation of the knowledge of health professionals at a pediatric hospital regarding the use of metered-dose inhalers]

OBJECTIVE

To evaluate health professionals working at a tertiary pediatric hospital in terms of their knowledge regarding the practical use of metered-dose inhalers.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Regular treatment with salmeterol for chronic asthma: serious adverse events

BACKGROUND

Epidemiological evidence has suggested a link between beta-agonists and increases in asthma mortality. There has been much debate about possible causal links for this association, and whether regular (daily) long-acting beta(2)-agonists are safe.

OBJECTIVES

The aim of this review is to assess the risk of fatal and non-fatal serious adverse events in trials that randomised patients with chronic asthma to regular salmeterol versus placebo or regular short-acting beta(2)-agonists.

SEARCH STRATEGY

Trials were identified using the Cochrane Airways Group Specialised Register of trials. Web sites of clinical trial registers were checked for unpublished trial data and FDA submissions in relation to salmeterol were also checked. The date of the most recent search was October 2007.

SELECTION CRITERIA

Controlled parallel design clinical trials on patients of any age and severity of asthma were included if they randomised patients to treatment with regular salmeterol and were of at least 12 weeks duration. Concomitant use of inhaled corticosteroids was allowed, as long as this was not part of the randomised treatment regimen.

DATA COLLECTION AND ANALYSIS

Two authors independently selected trials for inclusion in the review. Outcome data was extracted by one author and checked by the second author. Unpublished data on mortality and serious adverse events was sought.

MAIN RESULTS

The review includes 26 trials comparing salmeterol to placebo and 8 trials comparing with salbutamol. These included 62,630 participants with asthma (including 2,380 children). In 6 trials (2,766 patients), no serious adverse event data could be obtained. All cause mortality was higher with regular salmeterol than placebo but the increase was not significant, Odds Ratio 1.33 [95% CI: 0.85, 2.10]. Non-fatal serious adverse events were significantly increased when regular salmeterol was compared with placebo, Odds Ratio 1.14 [95% CI: 1.01, 1.28]. One extra serious adverse event occurred over 28 weeks for every 188 people treated with regular salmeterol [95% CI: 95 to 2606]. There is insufficient evidence to assess whether the risk in children is higher or lower than in adults. No significant increase in fatal or non-fatal serious adverse events was found when regular salmeterol was compared with regular salbutamol. Individual patient data from the SNS study have been combined with the results of the SMART study; in patients who were not taking inhaled corticosteroids, compared to regular salbutamol or placebo, there was a significant increase in risk of asthma-related death with regular salmeterol, Odds Ratio 9.52 [95% CI: 1.24, 73.09]. The confidence interval for patients taking inhaled corticosteroids is too wide to rule out an increase in asthma mortality in this group.

AUTHORS' CONCLUSIONS

In comparison with placebo, we have found an increased risk of serious adverse events with regular salmeterol. There is also a clear increase in risk of asthma-related mortality in patients not using inhaled corticosteroids in the two large surveillance studies. Although the increase in asthma-related mortality was smaller in patients taking inhaled corticosteroids at baseline, the confidence interval is wide, so it cannot be concluded that the inhaled corticosteroids abolish the risks of regular salmeterol. The adverse effects of regular salmeterol in children remain uncertain due to the small number of children studied.

Teaching time for metered-dose inhalers in the emergency setting

OBJECTIVES

In some acute-care settings, practitioners are reluctant to institute bronchodilator therapy with metered-dose inhalers (MDIs) as standard management. Such therapy requires that personnel ensure optimal use of these devices. We prospectively evaluated the time required to teach patients correct inhaler use for the emergency treatment of asthma and COPD, and patient factors associated with duration of teaching.

DESIGN

MDI arm within a single-center randomized clinical trial comparing bronchodilator administration by MDI with a delivery enhancement device (MDI/DED) vs delivery by wet nebulizer.

SETTING

All subjects were treated for asthma or COPD exacerbations at the respiratory acute-care day hospital of the Montreal Chest Institute, immediately after presentation to our emergency department. Inhaler-use education was provided according to a predetermined protocol.

MEASUREMENTS

Subjects' baseline characteristics were obtained from medical charts, spirometry, and questionnaires; satisfaction was evaluated by questionnaire. All inhaler-use education was observed and timed.

RESULTS

Sixty-one patients with asthma (median age, 46 years) and 32 patients with COPD (median age, 68.5 years) were randomized to treatment by MDI/DED. Mean FEV1 (percent predicted) was 63.5% for patients with asthma and 39.5% for patients with COPD. Five patients could not complete MDI teaching and therefore received subsequent treatment by wet nebulization. For the 88 other patients, the median teaching time was 6.5 min. Shorter teaching-time requirements were independently associated with higher initial arterial oxygen saturation, home DED use after previous MDI instruction, and a single initial bronchodilator treatment by wet nebulization. Most subjects expressed satisfaction with MDI/DED teaching and treatment.

CONCLUSIONS

Successful MDI/DED teaching followed by self-medication is feasible in the emergency setting, based on a simple protocol. A single bronchodilator dose administered by wet nebulization may facilitate subsequent MDI teaching.

A comparison of albuterol administered by metered-dose inhaler and spacer with albuterol by nebulizer in adults presenting to an urban emergency department with acute asthma

STUDY OBJECTIVES

To determine the efficacy of albuterol by metered-dose inhaler (MDI) and spacer compared to a nebulizer.

DESIGN

A prospective, open-label study.

SETTING

Large urban emergency department (ED).

PATIENTS

All consecutive adult asthma patients over a 2.5-year period.

INTERVENTIONS

ED personnel used a standardized treatment algorithm, which included albuterol administered by nebulization, for patients presenting to the ED during the first 12 months of the study. The treatment algorithm then was switched to one that utilized albuterol administered by MDI/spacer as the primary mode of delivery for the following 18 months. As part of the conversion to MDI/spacer, ED staff counseled patients on self-management and supplied patients with a peak flowmeter, an MDI/spacer, and an inhaled steroid for home use.

MEASUREMENTS

Pulmonary function, clinical outcome, laboratory data, and financial data were assembled and analyzed from 2,342 ED visits and 1,420 patients.

RESULTS

While there was no significant difference in hospital admission rates between patients in the MDI/spacer group and the nebulizer group (13.2% and 14.6%, respectively), there was a statistically greater improvement in peak flow rates in the MDI/spacer group (126.8 vs 111.9 L/min, respectively; p = 0.002). The MDI/spacer group also spent significantly less time in the ED (163.6 and 175 min, respectively; p = 0.007), had a lower total albuterol dose (1,125 microg and 6,700 microg, respectively; p < 0.001), and showed a greater improvement in arterial oxygen saturation (p = 0.043). Relapse rates at 14 and 21 days were significantly lower (p < 0.01 and p < 0.05, respectively) among patients treated with the MDI/spacer and were associated with asthma education and the provision of a peak flowmeter, a spacer, and an inhaled corticosteroid for patients' home use.

CONCLUSIONS

Albuterol administered by MDI/spacer is an efficacious and cost-effective alternative to nebulization in adults with acute asthma who present at a large urban ED.