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Editor,—Zar and colleagues compared homemade spacers with two commercially available valved holding chambers (VHCs) for the treatment of children with acute asthma.1 We, as the manufacturer of one of the VHCs that was evaluated, acknowledge that the practice of using empty drink bottles is common in some countries (either by necessity or choice), but we are highly concerned about the support to the hypothesis, given by implication in this paper, that coffee cup or drink bottle spacers are as effective as properly designed add on devices.
In this paper, the production technique did not simulate the release of medication from a pressurised metered dose inhaler (pMDI). Instead, the technique created a radio labelled aerosol by pneumatic nebulisation into a bag (which would have acted as a particle pre-selector). This set up would not have reproduced accurately the ballistic component (polydispersed particles) that is inevitably released at actuation of a pMDI. It has already been shown that these particles are more effectively separated by a VHC than a spacer (with no valve). Had a pMDI containing the radio-labelled aerosol been used (as is the normal practice in gamma scintigraphic studies evaluating pMDI systems), we believe that the dynamic aerosol behaviour (inertial impaction of the ballistic component, turbulent deposition, etc) following actuation into the chamber would have been quite different to that observed by having patients drawing in the already formed aerosol from an anaesthesia bag. Simply put, the protocol more closely simulated a continuous jet nebuliser releasing a liquid phase aerosol into a bag that was then connected to a chamber/spacer device, and may therefore have little relevance to what occurs inside a VHC used with a pMDI.
A well designed holding chamber (with a valve) will retain a significant portion of the coarse component of the emitted dose (particles greater than about five microns aerodynamic diameter) from the pMDI. A spacer (homemade or otherwise) will not perform this function effectively. Rather, it will momentarily contain the aerosol and then deliver particles of all sizes to the well coordinated patient who is able to time inhalation with actuation of the pMDI. In the case of corticosteroids, the emitted coarser particles can promote local topical infections—such as, oral candidiasis, as well as increases in overall systemic absorption.
The inhalation valve, which distinguishes a VHC from a spacer, needs to be a carefully designed component whose function is to retain the aerosol once created following actuation of the pMDI, then release it during the inspiratory cycle. Many children, particularly those with an acute exacerbation of asthmatic symptoms, have poor coordination, and are therefore likely to mistime inhalation with pMDI actuation. These patients, who are at greatest risk, are thus likely to derive least benefit from the use of homemade spacers.
Although we have other observations of a technical nature, the information given here should be sufficient to provide the message that this study should not be taken as the final word but rather as a finding concerning the debate about the efficacy of homemadev manufactured add on delivery devices for use in pMDI based treatment.
That said, if a VHC is unavailable for whatever reason, an empty drinking bottle may be better than nothing at all.
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