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Asthma - Management
What should I consider when choosing a delivery system?
- When choosing an inhaler device for a person with asthma, consider:
- The availability of the drug and dose in the specific device.
- The ability of the person to develop and maintain an effective technique with the specific device — this may depend on such factors as age, dexterity, coordination, and inspiratory flow.
- The suitability of the device to the person's (and carer's) lifestyles, considering such factors as portability and convenience.
- The person's preference for and willingness to use a particular device.
- Cost — choose the device with the lowest overall cost (taking into account daily required dose and product price per dose).
- Good technique is essential in ensuring the correct use of inhaler devices. Only prescribe inhalers after the person using them (or their carer) has received training in the use of the device and has demonstrated acceptable technique.
Clarification / Additional information
- A wide variety of devices, masks, and spacers are used to deliver inhaled drugs, including:
- Pressurized metered-dose inhalers.
- Breath-actuated metered-dose inhalers.
- Dry-powder inhalers.
- Spacer devices with a variety of different volumes.
- Face masks with a variety of designs.
- Nebulizers, driven by air or oxygen.
- For a full list of available devices, see www.bnf.org.
- Prescribers should familiarize themselves with a selection of these devices so they can inform, supervise, and assist patients appropriately.
- Dry-powder devices and breath-actuated metered-dose inhalers require an inspiratory flow of at least 30 L/min to activate the device. Some frail people and younger children cannot consistently achieve the required minimum inspiratory flow rate [NICE, 2002].
- Table 1 shows suggested minimum age requirements for the correct use of inhaled drug delivery devices.
Table 1. Age requirements for correct use of inhaler delivery devices.
Delivery system | Minimum age |
|---|
pMDI | > 5 years |
pMDI with spacer | > 4 years |
pMDI with spacer and mask | 4 years or younger |
Breath-actuated metered-dose inhaler | > 5 years |
Dry-powder inhaler | 5 years or older |
pMDI = pressurized metered-dose inhaler. |
[Dolovich et al, 2005]
Basis for recommendation
- A number of factors guiding the choice of inhaler device have been identified in the literature [MeReC, 2002; Dolovich et al, 2005; SIGN and BTS, 2009].
- Systematic reviews have found no evidence that alternative inhaler devices are clinically more effective than standard pressurized metered-dose inhalers (pMDIs) for delivering beta2-agonist bronchodilators or inhaled corticosteroids [Brocklebank et al, 2001; Ram et al, 2001]. On this basis, if used correctly, pMDIs are the most cost-effective inhaler devices:
- Studies often select for people who can use each of the devices appropriately, or they provide intensive training to ensure that the appropriate technique is used [Dolovich et al, 2005]. Therefore, in practice, efficacy may differ among individuals.
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