Delivery of Medications by Metered Dose Inhaler Through a Chamber/Mask to Young Children with Asthma

Abstract

Delivery of inhaled medications to children with asthma by a small-volume nebulizer is an antiquated method. Delivery by metered dose inhaler through a valved holding chamber with mask is at least equally effective, but more convenient, safer, faster, and less expensive. In addition, antistatic chambers increase the amount of drug delivered to the airways. This is an advantage for albuterol, but could increase the risk of long-term systemic adverse effects of inhaled corticosteroids at higher doses. Comparison with Nebulizer DeliveryI n children under five years of age, inhaled medications are difficult to administer. The only two methods of medication delivery to this age group are the metered dose inhaler through a valved holding chamber with mask (MDI + VHC) and the small-volume nebulizer (SVN). Both can be used to administer a short-acting beta-agonist and an inhaled corticosteroid (ICS). However, the MDI + VHC method has several advantages over nebulizer delivery. [1][2][3][4][5] The MDI + VHC is more efficient, faster, more convenient, and less expensive than the SVN. 5,6 Furthermore, in the emergency department treatment of asthma in children 5-17 years, when albuterol was given by MDI + VHC with mouthpiece (6-10 puffs per dose repeated at 20-min intervals), there was less tachycardia than when given by nebulizer. 2 Finally, in children under five years of age with moderate-to-severe asthma exacerbations treated in the emergency department, albuterol given by MDI + VHC was more effective than by a nebulizer in decreasing hospitalization and improving clinical score. 1 However, prescribers and parents of young children often believe that a nebulizer is more effective than an MDI + VHC. On the contrary, it has been shown that 4-10 puffs of albuterol sulfate delivered by MDI + VHC per dose is as effective as 2.5 mg of albuterol delivered by SVN when both are administered at 15-30-min intervals to infants and preschool children. 4,5,7,8 The results of these studies apply to home treatment of exacerbations. However, another disadvantage of home nebulizer administration is that pathogenic organisms can be transmitted when nebulizers are not disinfected. 9 Budesonide inhalation suspension (Pulmicort Respules Ò and generics) is the only ICS available in the United States for nebulization. There are no studies comparing the delivery of budesonide by nebulizer to delivery by MDI + VHC in young children. However, a randomized, double-blind, placebo-controlled study has shown that fluticasone delivered through an MDI + VHC improves pulmonary function and controls symptoms in infants with recurrent wheeze. 10 Other studies have substantiated improved asthma control when an MDI + VHC was used to deliver fluticasone in children < 2 years as well as older preschool children. [11][12][13][14][15] Thus, the MDI + VHC is an efficient and effective way to deliver both albuterol and ICS to young children. However, as children get older, there is less rationale for using a VHC. For older children who can breath-hold, a dry powd...