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Use of metered dose and dry powder inhalers in children

INTRODUCTION

The pressurized metered dose inhaler (pMDI) has been a mainstay in the treatment of respiratory diseases, especially asthma, since being introduced in 1956, and is the most commonly prescribed delivery system for administering inhaled bronchodilators and anti-inflammatory agents worldwide [1,2]. Spacer devices, when used properly, substantially improve the delivery of pMDI-generated aerosols to the distal airways. For most patients, the pMDI, used alone or in combination with a spacer or valved-holding chamber, is the most convenient and cost-effective way to administer aerosolized medications.

Dry powder inhalers (DPI) are a separate group of medication aerosolizing devices widely used in the management of adult and pediatric pulmonary disease. These devices eliminate the need for propellants, and are less dependent on coordination of inhalation and device actuation. Currently, short- and long-acting beta agonists and inhaled corticosteroids are available for administration via DPIs.

The effectiveness of both delivery systems is dependent on several factors including the properties of the agent administered, design, temperature, humidity, and patient technique [3,4]. The use of pMDIs and DPIs in children will be discussed here. Other aspects of aerosol therapy, including the use of nebulizers, are presented separately. (See "Delivery of inhaled medication in children" and "Use of medication nebulizers in children".)

PRESSURIZED METERED DOSE INHALERS

A pMDI contains drug, which usually is either crystallized or in solution, along with the propellant and a surfactant (figure 1) [2].

Propellants — Up to 80 percent of the aerosol generated is propellant, historically a chlorofluorocarbon (CFC) such as freon. When pMDIs containing CFC were actuated directly into the mouth, the cold blast resulting from the impact of particles in the pharynx (the cold-freon effect) caused some patients to abort the inhalation of drug [4]. In addition, inhalation of CFC with pMDI use has been reported to promote paradoxical bronchoconstriction in some asthmatic patients [5].
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