The use of metered-dose inhaler versus nebulization for the delivery of salbutamol in pediatric severe asthma exacerbations: A systematic review

BACKGROUND@#Recent guidelines for the management of asthma have advocated the use of a pressurized metered-dose inhaler (MDI) and spacer in the delivery of salbutamol. However, there is a dearth of research in children with severe exacerbation.@*OBJECTIVES@#To compare the effectiveness of MDI with spacers versus nebulizers in drug delivery of salbutamol for the management of pediatric severe asthma exacerbations. @*METHODOLOGY@#A systematic search of the Pubmed, Cochrane library, Herdin, WPRIM, ClinicalTrials and reference review databases was conducted for studies containing “severe asthma” using MDI and spacer as an intervention with nebulization as a comparator.@*RESULTS@#Of 220 articles, 4 met the criteria. In the subgroup analysis, children who received salbutamol through MDI showed no significant difference in hospital admission, pulmonary score, heart and respiratory rate, oxygen saturation, and lung function.@*CONCLUSION@#In severe asthma exacerbations, there is evidence to support that MDI compared with nebulizer is statistically equal in terms of hospital admission, pulmonary scores, clinical improvement, and side effects@*RECOMMENDATIONS@#Further randomized controlled trials are suggested to explore the intricacies of drug delivery in management of severe asthma. A meta-analysis may be made possible in the future with more evidence.

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La crisis climática es una enorme amenaza para la salud humana. La evidencia que el cambio climático está ocurriendo es abrumadora, impulsado por actividades humanas que aumentan los gases de efecto invernadero en la atmósfera. Los inhaladores de dosis medidas presurizados utilizaban propulsores de clorofluorocarbonos. Los propulsores de clorofluorocarbonos fueron prohibidos debido a su gran impacto en el agotamiento de la capa de ozono. El protocolo de Montreal, introducido para proteger la capa de ozono, estableció una eliminación planificada de los clorofluorocarbonos, reemplazándolos con los hidrofluorocarbonos que ahora se utilizan en los inhaladores de dosis medidas presurizados. Si bien los hidrofluorocarbonos no agotan la capa de ozono, son potentes gases de efecto invernadero tienen un potencial de calentamiento global muchas veces mayor que el del dióxido de carbono. El sector de la salud es un contribuyente significativo a las emisiones de gases de efecto invernadero a nivel mundial. Los aumentos de la temperatura global ya están teniendo un impacto significativo en nuestro clima. La lucha contra el cambio climático se ha descrito como la mayor oportunidad de salud pública del siglo XXI. Para reducir el impacto de los inhaladores en el cambio climático, hay varias opciones disponibles, incluidas el reciclaje de los inhaladores, el uso de dispositivos alternativos, reducir la cantidad del propulsor por dosis o usar un propulsor con un potencial de calentamiento global menor. Los profesionales sanitarios tenemos el deber de proteger y promover la salud de los pacientes y emprender acciones para disminuir los peores efectos del cambio climático. Se deben hacer todos los esfuerzos posibles para minimizar la emisión de gases de efecto invernadero si queremos proteger a las generaciones actuales y futuras.

The climate crisis is a massive threat to human health. The evidence that climate change is happening, driven by human activities which increase atmospheric greenhouse gases, is overwhelming. Pressurized metered-dose inhalers used chlorofluorocarbons propellants. Chlorofluorocarbons propellants were banned because of their big impact on the ozone layer depletion. The Montreal Protocol, introduced to protect the ozone layer, saw a planned phase-out of chlorofluorocarbons, replacing them with the hydrofluorocarbons now used in metered-dose inhalers used. While hydrofluorocarbons are not ozone depleting, they are potent greenhouse gases and have global warming potential many times that of carbon dioxide. The healthcare sector is a significant contributor to greenhouse gases emissions globally. Increases in global temperature are already having a significant impact on our climate. Combating climate change has been described as 'the greatest public health opportunity of the 21st century. To reduce the climate change impact of inhalers, several options are available including inhaler recycling, the use of alternatives devices, reduce the propellant quantity per dose or use a different propellant with a lower global warming potential. Healthcare professionals have a duty to protect and promote the health of patients and take actions to minimize the worst effects of climate change. Every effort must be made to minimize greenhouse gases release if we are to protect current and future generations

Assessment of Errors during Inhaler Usage among Asthma and COPD Patients.

BACKGROUND The cornerstone therapy for respiratory diseases is drugs for inhalation. Effectiveness of inhalers can be influenced by factors such as gender, age, educational status, and type of inhaler used and correct inhalation technique. The aim of this study is to provide information about common errors in technique that occur during inhalation.METHODSMale and female patients who met the inclusion criteria (age 18 - 80) years, using inhalers particularly MDI and DPI were included in the study. The study patients were asked to perform inhalation technique and the errors in technique that occur during inhalation were recorded. The sample size was 150 and duration of study was 6 months.RESULTSThe common errors during the use of inhalers included, no exhalation before inhalation, no breath hold, and absence of proper washing of mouth after inhalation. Among the 86 MDI users, no exhalation before inhalation (n=50), no breath hold (n=35) and absence of proper washing of mouth after inhalation (n=21). For the 64 patients using DPI, no exhalation before inhalation (n=68), no breath hold (n=51) and absence of proper washing of mouth after inhalation (n=35).

Acute exacerbations of asthma occurring frequently time to check your techniques

Background: Asthmatics form a predominant section of patients in OPD. If poorly controlled the frequency of attacks requiring an emergency department visit adds to the burden. It was noticed that the patients who were on inhalational therapy had poor control despite the absence of other factors which could lead to exacerbations. Hence author evaluated the inhalational techniques.Methods: A prospective study undertaken in the department of medicine in tertiary care hospital in Dakshina Kannada District, Karnataka enlisting 25 patients admitted with acute exacerbation of bronchial asthma. The patients were assessed for their symptoms, signs and recurrent attacks along with their cough severity index and inhaler scores and the observations were tabulated.Results: Of the twenty-five, 15 were on inhalation therapy with various modes of deliveries. There were 15 males and 10 females from ages 20 to 50years. The number of attacks of asthma was higher in those not on inhalation therapies than those using inhalation therapies. Also, the level/severity of cough, measured as Cough Severity Index, was assessed among the two groups. Those on inhalation therapy had a lower grade of cough than those not on therapy . Mean AEC was 94 among those on inhalation therapy and 209 among those not on therapy. Inhalational score was calculated for each patient. There is a strong negative correlation of -0.709 between inhalation score and recurrent attacks, which is statistically significant (p=0.003). Lower inhalation scores were associated with recurrent attacks.Conclusions: Recurrent exacerbations in an asthmatic patient on inhalation therapy are due to improper inhalational technique. It was suggested that it is wise to spend time with the patients in authors OPD set up and teach them the correct techniques of using inhalational therapy hence reducing frequency of attacks and cost of health care in such patients.

Comparação de duas técnicas inalatórias para administrar broncodilatador em crianças e adolescentes com crise aguda de asma: metanálise / Comparison of two inhalational techniques for bronchodilator administration in children and adolescents with acute asthma crisis: a meta-analysis

RESUMO Objetivo: Comparar a eficácia no tratamento da asma pediátrica por nebulizador e inalador dosimetrado com uso de espaçador (MDI-espaçador), no emprego das técnicas de resgate de pacientes asmáticos atendidos em emergências pediátricas. Fontes de dados: Realizou-se uma revisão sistemática para identificar os principais estudos randomizados controlados que comparam a administração de broncodilatador (β-2 agonista) por meio das técnicas inalatórias nebulização e MDI-espaçador no tratamento da asma em unidades de emergência pediátrica. Foram pesquisadas as bases de dados PubMed, Scientific Electronic Library Online (SciELO) e ScienceDirect. Dois pesquisadores, de forma independente, aplicaram os critérios de elegibilidade, sendo incluídos na pesquisa apenas estudos randomizados controlados com o objetivo de comparar as técnicas inalatórias nebulização e MDI-espaçador no tratamento da asma em unidades de emergência pediátrica. Síntese dos dados: Foram pré-selecionados 212 artigos, dos quais apenas nove seguiram os critérios de elegibilidade e foram incluídos na metanálise. Os resultados apontam não existir diferenças nas técnicas inalatórias em nenhum dos quatro desfechos analisados: frequência cardíaca (diferença -Df: 1,99 [intervalo de confiança de 95% - IC95% -2,01-6,00]); frequência respiratória (Df: 0,11 [IC95% -1,35-1,56]); saturação de O2 (Df: -0,01 [IC95% -0,50-0,48]); e escore clínico de asma (Df: 0,06 [IC95% -0,26-0,38]). Conclusões: Os achados demonstram não haver diferenças na frequência cardiorrespiratória, na saturação de O2 nem nos escores de asma, na administração de β-2 agonista entre as técnicas inalatórias (nebulizador e MDI-espaçador) em pacientes asmáticos atendidos em emergências pediátricas.

ABSTRACT Objective: To compare the efficacy of pediatric asthma treatment by nebulizer and metered-dose inhaler with the use of a spacer (MDI-spacer) in rescue techniques for asthmatic patients assisted at pediatric emergency units. Data sources: A systematic review was conducted to identify the most relevant randomized controlled trials comparing the administration of a bronchodilator (β-2 agonist) by two inhalation techniques (nebulization and MDI-spacer) to treat asthma in children at pediatric emergency units. The following databases were searched: PubMed, Scientific Electronic Library Online (SciELO), and ScienceDirect. Two researchers independently applied the eligibility criteria, and only randomized controlled trials that compared both inhalation techniques (nebulization and MDI-spacer) for asthma treatment at pediatric emergency units were included. Data synthesis: 212 articles were pre-selected, of which only nine met the eligibility criteria and were included in meta-analysis. Results show no differences between inhalation techniques for any of the four outcomes analyzed: heart rate (difference - Df: 1.99 [95% confidence interval - 95%CI -2.01-6.00]); respiratory rate (Df: 0.11 [95%CI -1.35-1.56]); O2 saturation (Df: -0.01 [95%CI -0.50-0.48]); and asthma score (Df: 0.06 [95%CI -0,26-0.38]). Conclusions: The findings demonstrate no differences in cardiorespiratory frequency, O2 saturation, and asthma scores upon administration of β-2 agonist by both inhalation techniques (nebulization and MDI-spacer) to asthmatic patients assisted at pediatric emergency units.

An evaluation of Metered-Dose Inhaler Administration Technique in Patients of Asthma and Chronic Obstructive Pulmonary Disease.

Objectives: To evaluate the technique of use of metered dose inhaler (MDI) in patients of asthma or chronic obstructive pulmonary disease (COPD) patients at a tertiary health care hospital. Materials and methods: This was a cross-sectional observational study conducted in the patients of bronchial asthma and COPD who were prescribed MDI. The method to use MDI was assessed by using checklist made by WHO Guide to Good Prescribing. Results: A total of 193 patients (128 COPD, 65 asthma) were included. Majority of patients (95%) were educated by the treating physician for the use of inhalational technique of MDI. Majority of patients (98.4%) followed the step to place the lips tightly around the mouthpiece. While the least followed steps were coughing up as much sputum as possible (14.5%), breathing out through nose (15%) and rinsing the mouth after use (22.8%). Conclusion: Few steps of MDI use were missed in majority of the patients. This can be improved by demonstration and by providing awareness by the health care worker.

Leachables in metered-dose inhaler packages: Research advances / 国际药学研究杂志

The container closure system is indispensable to metered-dose inhaler (MDI). In the shelf life of MDI, various ingredients of the container closure system may become potential leachables and migrate into the preparation. Due to their unknown constructs and latent ambiguous toxicities, leachables may significantly affect drugs’ effectiveness and safety. Consequently, it is necessary to carry on leachable studies to ensure the good compatibility of MDI closure system. This paper mainly focuses on the fundamental components of MDI container closure system, analyzes leachable sources and safety information and reviews the related contents about leachable studies in domestic and foreign pharmacopoeia.

Determination methods for in vitro deposition of metered dose inhalers: Differences of three impactors / 国际药学研究杂志

Objective To analyze and compare fine particle fraction (FPF) and particle size distribution (PSD) measured by twin-stage impactor(TSI), Andersen cascade impactor (ACI) and next generation pharmaceutical impactor(NGI). Methods Selfmade metered dose inhaler(MDI) of fluticasone propionate was selected as the model drug, and the FPF and PSD were determined by TSI, ACI and NGI. Results The device of TSI was simple, and fine particle drug dose with less than 6.4 micrometer aerodynamic diameter size was acquired quickly, and the recovery rate was relatively high under the good seal, but aerodynamic diameter distribution was not obtained. In contrast, both the aerodynamic diameter and particle size distribution were obtained with ACI and NGI. Different from ACI, for NGI it was not necessary to wash the sieves, although NGI is heavy. So, the operation of NGI is simpler. Conclusion NGI can be chosen as the priority for the determination of the aerodynamics related parameters.

Leachables in metered-dose inhaler packages:research advances / 国际药学研究杂志

The container closure system is indispensable to metered-dose inhaler(MDI). In the shelf life of MDI,various in?gredients of the container closure system may become potential leachables and migrate into the preparation. Due to their unknown con?structs and latent ambiguous toxicities,leachables may significantly affect drugs′effectiveness and safety. Consequently,it is neces?sary to carry on leachable studies to ensure the good compatibility of MDI closure system. This paper mainly focuses on the fundamen?tal components of MDI container closure system,analyzes leachable sources and safety information and reviews the related contents about leachable studies in domestic and foreign pharmacopoeia.

Determination methods for in vitro deposition of metered dose inhalers:differences of three impactors / 国际药学研究杂志

Objective To analyze and compare fine particle fraction(FPF)and particle size distribution(PSD)measured by twin-stage impactor(TSI),Andersen cascade impactor(ACI)and next generation pharmaceutical impactor(NGI). Methods Self-made metered dose inhaler(MDI) of fluticasone propionate was selected as the model drug,and the FPF and PSD were determined by TSI,ACI and NGI. Results The device of TSI was simple,and fine particle drug dose with less than 6.4 micrometer aerodynamic di?ameter size was acquired quickly,and the recovery rate was relatively high under the good seal,but aerodynamic diameter distribution was not obtained. In contrast,both the aerodynamic diameter and particle size distribution were obtained with ACI and NGI. Different from ACI,for NGI it was not necessary to wash the sieves,although NGI is heavy. So,the operation of NGI is simpler. Conclusion NGI can be chosen as the priority for the determination of the aerodynamics related parameters.

Evaluación del conocimiento de los padres de la técnica de aerosolterapia con aerocámara / Evaluation of parental knowledge of the aerosol technique with holding chamber

Introducción. Los episodios de tos, disnea y sibilancias son causa frecuente de consulta pediátrica. Su tratamiento de elección es la administración de fármacos a través de la aerosolterapia. El éxito de esta estrategia depende de la correcta aplicación de la técnica inhalatoria. Objetivo. Evaluar el conocimiento de padres de niños con patología obstructiva recurrente de la vía aérea en el uso de la aerosolterapia con aerocámara. Población y métodos. Estudio transversal, observacional, descriptivo. Se incluyeron aleatoriamente padres de niños menores de 6 años con tos, disnea y/o sibilancias con antecedentes de uso de aerocámara en la consulta al Servicio de Pediatría y/o de Alergia e Inmunología. Se evaluó el conocimiento en el empleo del inhalador mediante observación de la técnica. Resultados. Se incluyeron 114 niños, 51% masculino, con una edad promedio de 29,23 meses (DE=18,30). La persona a cargo de realizar la aerosolterapia tenía una media de edad de 32,28 años (DE=5,29); la mayoría de los responsables evaluados fueron madres (92,98%), con nivel de educación superior (71,05%). La forma de aprendizaje de la técnica fue demostrativa visual en 62 casos (54,4%), y el principal instructor de la misma fue el pediatra. Se demostró que 68 (72%) padres no realizaban en forma correcta la técnica y se encontró asociación entre edad del paciente y la correcta realización de la aerosolterapia (r=0,21; p=0,03). Conclusión. La mayoría de los padres realizan la aerosolterapia de forma incorrecta y la edad del niño influye en la técnica de la terapia inhalatoria.(AU)

Introduction. Symptoms of cough, dyspnea and wheezing are common cause for medical consultation. Their treatment is the administration of drugs through the aerosol. The success of this strategy depends on the correct application of inhalation technique. Objective. To evaluate the knowledge of parents of children with recurrent obstructive airway disease in the use of aerosol therapy with valved holding chamber. Population and Methods. Cross-sectional, observational, descriptive study. Randomly included parents of children under six years with cough, dyspnea and / or wheezing with a background of use in the office holding chamber of Pediatric and / or of Allergy and Immunology section of an Hospital. We evaluated the knowledge about the inhaler technique by medical observation. Results. We included 114 children, 51% male, with an average age of 29.23 months (SD=18.30). The median age o the caregiver responsible for conducting the aerosol therapy was 32.28 years (SD=5.29); the majority of evaluated makers were mothers (92.98%) with higher education level (71.05%). The most frequent way for learning was the visual demonstration technique in 62 cases (54.4%), and the main instructor was the pediatrician. Sixty-eight (72%) of parents did not perform properly the inhalation technique and a positive association was found between patient age and the proper realization of the aerosol (r=0.21; P=0.03). Conclusion. Most parents perform incorrectly aerosol therapy with valved holding chamber and the child's age influences the inhalation technique.(AU)

Effectiveness of Same Versus Mixed Asthma Inhaler Devices: A Retrospective Observational Study in Primary Care

PURPOSE: Correct use of inhaler devices is fundamental to effective asthma management but represents an important challenge for patients. The correct inhalation manoeuvre differs markedly for different inhaler types. The objective of this study was to compare outcomes for patients prescribed the same inhaler device versus mixed device types for asthma controller and reliever therapy. METHODS: This retrospective observational study identified patients with asthma (ages 4-80 years) in a large primary care database who were prescribed an inhaled corticosteroid (ICS) for the first time. We compared outcomes for patients prescribed the same breath-actuated inhaler (BAI) for ICS controller and salbutamol reliever versus mixed devices (BAI for controller and pressurised metered-dose inhaler [pMDI] for reliever). The 2-year study included 1 baseline year before the ICS prescription (to identify and correct for confounding factors) and 1 outcome year. Endpoints were asthma control (defined as no hospital attendance for asthma, oral corticosteroids, or antibiotics for lower respiratory tract infection) and severe exacerbations (hospitalisation or oral corticosteroids for asthma). RESULTS: Patients prescribed the same device (n=3,428) were significantly more likely to achieve asthma control (adjusted odds ratio, 1.15; 95% confidence interval [CI], 1.02-1.28) and recorded significantly lower severe exacerbation rates (adjusted rate ratio, 0.79; 95% CI, 0.68-0.93) than those prescribed mixed devices (n=5,452). CONCLUSIONS: These findings suggest that, when possible, the same device should be prescribed for both ICS and reliever therapy when patients are initiating ICS.

Skills in Handling Turbuhaler, Diskus, and Pressurized Metered-Dose Inhaler in Korean Asthmatic Patients

PURPOSE: The objective of this study was to evaluate skills in handling inhalers and factors associated with these skills among patients with asthma who had undergone treatment at special asthma and allergy clinics in Korea. METHODS: We enrolled 78 subjects who used Turbuhaler and 145 who used Diskus for asthma control at special clinics in 10 university hospitals and visually assessed their skills in handling these inhalers. We also evaluated skills in 137 subjects who had used pressurized metered-dose inhalers (pMDIs) for symptom relief. Age, sex, duration of asthma and inhaler use, smoking status, monthly income, highest grade completed in school and previous instruction for handling inhalers were also measured to evaluate their association with overall inhaler skills. RESULTS: Performance grade was inadequate for 12.8% of participants using Turbuhaler, 6.2% for Diskus, and 23.4% for pMDIs. The success rates for each step in handling the inhalers were relatively high except for the "exhale slowly to residual volume" step, in which success rates ranged from 24.2% to 28.5%. Older age, male sex, lower educational grade, and absence of previous instruction for handling inhalers were associated with inadequate inhaler technique in univariate analysis; however, only older age and absence of previous instruction remained significant independent risk factors in multivariate analysis. CONCLUSIONS: Among Korean asthmatic patients in special asthma and allergy clinics, skills in handling their inhalers were mostly excellent; meanwhile, older age and absence of previous instruction for handling inhalers were associated with inadequate techniques.

Evaluation of an Education Program for Patients with Asthma who use Inhalers

PURPOSE: This study was done to evaluate the effectiveness of an education program for patients with asthma who use inhalers. METHODS: The research design for this study was a non-equivalent control group quasi-experimental study. Participants in this study were 36 patients for the control group, and 43 patients for the experimental group. The experimental group participated in the education program. The control group received the usual care. Data were collected before and 1 month and 2 months after the program finished and were analyzed using the SPSS 12.0 program. RESULTS: The experimental group had significantly higher scores of knowledge of inhalers, and inhalation technique compared to the control group. However, no significant differences were found between two groups for PEFR, asthma instability, and satisfaction with inhalers. CONCLUSION: According to the results, the education program was effective in improving knowledge of inhalers, and inhalation technique. Therefore, it is recommended that this education program be used in clinical practice as an effective nursing intervention for patients with asthma on inhalers.

HFA-134a driven salbutamol sulfate metered-dose inhaler: formulation screening and respiratory tract absorption in rats / 中国药科大学学报

Aim: To study the hydrofluoroalkane-driven(HFA-134a) salbutamol sulfate (SS) MDI formulation compositions and the respiratory tract absorption in rats. Methods: Solubility determination and orthogonal design were used to aid the screening of non-CFC SS MDI formulations. Rats were exposed to SS MDI via intubation inhalation. Fluorescent HPLC detection was developed to determine plasma SS concentration in rats given the selected SS MDI formulations. Analysis of the plasma drug level-time profiles was performed by the statistical moment approach. Results: Stable and homogeneous non-CFC SS MDI formulations were obtained. The developed HPLC method was validated and used to assay SS levels in the rats after inhalation of the MDI. AUC ratios of the SS/HFA-134a-driven MDI formulation to the reference SS MDI and CFC SS MDI formulation were 109. 86% and 135. 54%, respectively. Conclusion: It is proven that the absorption of the HFA-134a SS MDI formulation in rats is equivalent to the simulant formulation commercially available oversea and better than CFC formulation.

Tipos y características de los inhaladores para el manejo de asma / Types and characteristics of devices for the treatment of asthma

El tratamiento del asma requiere del uso de medicamentos durante períodos largos para lograr el control de la enfermedad y la vía inhalada es la forma más adecuada para administrarlos. En las últimas 2 décadas se han desarrollado nuevos y mejores dispositivos para la entrega del medicamento, con marcadas diferencias respecto a su diseño, construcción, características de salida y tamaño de las partículas. El médico debe conocer los puntos tecnológicos más destacados de cada aparato para que pueda aprovechar sus ventajas y haga recomendaciones muy precisas. Existen varios dispositivos para administrar medicamentos inhalados: los más viejos y de uso cotidiano en hospitales son los nebulizadores y de manera más reciente se introdujeron los inhaladores de dosis medida presurizados o los inhaladores de polvo seco, que son más usados para el paciente ambulatorio. La condición particular de cada uno de estos dispositivos debe conocerse y aplicarse para ofrecer el máximo beneficio al paciente asmático.

Asthma management requires the use of many drugs for long time with the purpose of achieving control. Inhalator delivery of asthma medications is the best way. In the previous 2 decades, technology has improved delivery devices, changes in design, materials and outsize particles. Physicians should know all the technical points in order to take advantage of these new devises to be able to make appropriate recommendations for their use. There is a large quantity of options for the delivery of asthma medications: nebulizers, metered dose inhaler and dry powder inhalers. Particular characteristics of delivery devices should be known and applied in particular patients.The aim of this review article is assist physicians to choose the best device option.

The effect of patient education on correct use of metered dose inhalers in patients with asthma / 천식및알레르기

BACKGROUND: Medications for asthma can be administered either by inhaled or systemic routes. The major advantages of delivering drugs directly into the lungs via inhalation are that higher concentrations can be delivered more effectively to the airways and that systemic side effects are avoided or minimized. Inhaled medications, or aerosols, are available in a variety of devices that differ in required technique and quantity of drugs delivered to the lung. OBJECTIVE: The purpose of this study was to determine the effects of patient education on correct use of metered dose inhaler in patients with asthma. METHODS: Twenty patients with asthma were instructed three times on proper inhaler usage by a physician at two-week intervals. Practical performance and theoretical knowledge were assessed (ten-item assessment). Scoring was done by one physician using a score of 1-3 for each item. RESULTS: The practical performance and theoretical knowledge scores were higher in patients after being instructed three times compared with those who were instructed once (26.2+/-2.2 vs 18.1+/-3.6, p< 0.01). The scores were higher in patients with higher education level com- pared with those with lower education level after three lessons (27.3+/-1.94 vs 24.3+/-1.80, p< 0.05). The most common errors included inadequate actuation time and breath holding, and insufficient activations. CONCLUSION: These findings suggest that patients with asthma be instructed in inhaler use and that their technique be checked regularly and repeatedly depending on education level.

Short-term Effects of Inhaled Corticosteroid Following Early Systemic Corticosteroid Administration in Premature Babies with Respiratory Distress Syndrome: A Preliminary Report

PURPOSE: To asses the short-term effects of the topical corticosteroid, budesonide administered by metered dose inhaler(MDI) and spacer(Aerochamber MV 15) following systemic corticosteroid in premature babies with respiratory distress syndrome at birth. METHODS: 19 premature babies <1800gm were randomly assigned to receive steroids(n=9) or not (n=10). The steroid group(n=9, GA[gestational age]=29.6+/-2.9 weeks, BW[birth weight]=1.29+/-0.35kg) received systemic dexamethasone for 48 hours since 12-24 hours after birth, followed by inhaled budesonide, 2 puffs per dose(400mcg of total dose), administered three times a day until extubation. The control group(n=10, GA=29.9+/-2.5 weeks, BW=1.32+/-0.26kg) did not receive steroids. The parameters of ventilator and arterial blood gases were recorded every 6 hours during the first 8 days of age, and the ventilatorty efficiency index(VEI) and the arterial/Alveolar Oz(a/A Op) ratios were calculated before administration, on the 4th and 8th days of age respectively. RESULTS: The steroid-treated group showed significant improvements in mean peak inspiratory pressure, fraction of inspired oxygen, VEI and a/A % ratio on the 4th and 8th day of age. There were no changes in the control group. The steroid-treated group tended to show a lower incidence of PDA and a lower need for systernic corticosteroids without significant differences, compared with those in the control group. CONCLUSION: Sequential early systemic corticosteroid adrninistration started within 24 hours of age, followed by inhhaled budesonide given by MDI and spacer(MDIS) was associated with clinical improvements in respiratory status and ventilator support in premature babies with respiratory distress syndrome.