To:
ADC Fetal and Neonatal Edition Letters and ADC Education and Practice Letters
Electronic Letters to:
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Electronic letters published:
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![[Read eLetter]](/icons/misc/sectionDOWN.gif)
Use of appropriate inhaler devices for optimal delivery of inhaled corticosteroids
- Samatha Sonnappa (30 July 2008)
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Re: Use of appropriate inhaler devices for optimal delivery of inhaled corticosteroids
- Steve Turner (1 September 2008)
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Appropriate inhaler devices for children with asthma
- Markku T Turpeinen, Helsinki University Hospital (3 September 2008)
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Use of approriate inhaler devices for optimal delivery of inhaled corticosteroids
- Markku T Turpeinen (4 September 2008)
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Samatha Sonnappa, Respiratory Paediatrician Dept. of Respiratory Medicine, Great Ormond St Hospital for Children & UCL Institute of Child Health
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s.sonnappa{at}ich.ucl.ac.uk Samatha Sonnappa
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The BTS guidelines on the management of asthma clearly state that in children aged 0-5 years, pressurised metered dose inhaler (pMDI) with spacer is the preferred method of delivery of inhaled corticosteroids (ICS); and in children aged 5-12 years and adults, dry powder inhalers (DPI) are as effective as pMDI with spacer (Grade A evidence).(1) The cover illustration of the August issue of the Archives shows a young boy with a pMDI with the title “Daily versus as-needed inhaled corticosteroid for mild persistent asthma”. There are a confusing number of choices of delivery devices for aerosol therapy and health-care professionals play a key-role in educating patients and care-givers to optimise inhaled drug delivery. Efficient delivery with pMDIs is highly technique dependent and not achieved in most Paediatric patients.(2) The NICE Guidance on asthma in children states that in England and Wales 60% of all patients (adults and children) diagnosed with asthma use pMDIs (with or without spacer), 17% use breath-actuated pMDIs, and 23% use DPIs.(3) Children with asthma and care-givers should be encouraged to use pMDIs with spacer or DPIs where indicated, for optimal delivery of ICS. The cover illustration as described above, in a journal endorsed by the RCPCH gives out wrong/confused signals to health-care professionals that the use of pMDIs alone, is acceptable practice. References (1) British Guideline on the Management of Asthma. Thorax 2008; 63 Suppl 4:iv1-121. (2) Hagmolen of ten Have, van de Berg NJ, Bindels PJ, van Aalderen WM, van der PJ. Assessment of inhalation technique in children in general practice: increased risk of incorrect performance with new device. J Asthma 2008; 45(1):67-71. (3) NICE Guidance. Corticosteroids for the treatment of chronic asthma in children under the age of 12 years. Asthma (in children) - corticosteroids. TA131. 2007. Ref Type: Report |
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Steve Turner, Senior Lecturer in Child Health University of Aberdeen
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s.w.turner{at}abdn.ac.uk Steve Turner
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Sir, Like Dr Sonnappa in London, I was very disappointed to see a picture on the front of this month’s Archives of a child using a pressurised metered dose inhaler (pMDI) without a spacer. This is the second such picture to appear on the front of Archives within the last 12 months and gives the wrong message to readers. The correct message is that pMDIs should not be used without a spacer device in children. The 2002 NICE document “guidance on inhalers for older children [5-15 years] with chronic asthma” states that pMDIs should be used with an appropriate spacer device(1). Adult chest physicians also recognise the importance of spacers to pMDIs efficacy; the 2008 BTS/SIGN guideline recommends that adults should receive high dose inhaled steroids with a pMDI-spacer combination(2). Spacers can be cumbersome and are often not favoured by older children. Dry powder devices can be used in older children where they are as equally effective as the pMDI-spacer combination(2). The evidence, which is echoed in the guidelines(1,2), is clear; pMDIs should not be used without a spacer in children of any age. A picture says a thousand words and I hope these 200 words go some way to correcting the misleading images on the cover of Archives. Steve Turner Senior Clinical Lecturer in Child Health University of Aberdeen 1. http://www.nice.org.uk/TA38 accessed 28/08/08 2. http://www.sign.ac.uk/pdf/sign101.pdf accessed 28/08/08 |
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Markku T Turpeinen, Paediatrician MD, PhD, Helsinki University Hospital
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markku.t.turpeinen{at}hus.fi Markku T Turpeinen, et al.
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Samatha Sonnappa brought out an important question about the use of appropriate inhaler devices in the treatment of asthma. In the present study in children 5-10 years of age we have solely used dry powder inhalers. The guidelines presented by Sonappa are the common recommendations in Finland as well: pressurised metered dose inhalers with spacer for children aged 0-5 years; and dry powder inhalers for children over 5 years of age and adults. The correct use of these devices needs always special instructions and teaching. N.B. The cover illustration for the article was not chosen by authors. However, the inappropriate inhalation technique presented in the cover image has already evoked a discussion about the importance of appropriate use of inhaler devices. |
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Markku T Turpeinen, Senior clinical lecturer Helsinki University Hospital
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markku.t.turpeinen{at}hus.fi Markku T Turpeinen
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We thank Dr Sonnappa and Dr Turner for their correct criticism about the use of inhaler devices for optimal delivery of inhaled corticosteroids. Concerning the present study, we would like to point out that dry powder inhalers were used for the inhaled corticosteroid and the beta-2-agonist according to the present guidelines. In order to achieve adequate teatment compliance, disodium cromoglycate was used as pressurised metered dose inhaler with a spacer. |
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