Papers

Systematic review of clinical effectiveness of pressurised metered dose inhalers versus other hand held inhaler devices for delivering ₂ agonists bronchodilators in asthma

Felix S F Ram, research fellow in respiratory medicine, ^a John Wright, consultant in clinical epidemiology and public health, ^a David Brocklebank, specialist registrar in respiratory medicine, ^a John E S White, consultant chest physician, ^b on behalf of the National Health Technology Assessment Inhaler Review Group.

^a Bradford Hospitals NHS Trust, Bradford Royal Infirmary, Bradford BD9 6RJ, ^b York Health Services NHS Trust, Department of Respiratory Medicine, York District Hospital, York YO3 7HE

Correspondence to: J Wright john.wright{at}bradfordhospitals.nhs.uk

Objectives: To determine the clinical effectiveness of pressurised metered dose inhalers compared with other hand held inhaler devices for delivering short acting ₂ agonists in stable asthma.
Design: Systematic review of randomised controlled trials.
Data sources: Cochrane Airways Group specialised trials database (which includes hand searching of 20 relevant journals), Medline, Embase, Cochrane controlled clinical trials register, pharmaceutical companies, and bibliographies of included trials.
Trials: All trials in children or adults with stable asthma that compared the pressurised metered dose inhaler (with or without a spacer device) against any other hand held inhaler device containing the same ₂ agonist.
Results: 84 randomised controlled trials were included. No differences were found between the pressurised metered dose inhaler and any other hand held inhaler device for lung function, blood pressure, symptoms, bronchial hyperreactivity, systemic bioavailability, inhaled steroid requirement, serum potassium concentration, and use of additional relief bronchodilators. In adults, pulse rate was lower in those using the pressurised metered dose inhaler compared with those using Turbohaler (standardised mean difference 0.44, 95% confidence interval 0.05 to 0.84); patients preferred the pressurised metered dose inhaler to the Rotahaler (relative risk 0.53, 95% confidence interval 0.36 to 0.78); hydrofluoroalkane pressurised metered dose inhalers reduced the requirement for rescue short course oral steroids (relative risk 0.67, 0.49 to 0.91).
Conclusions: No evidence was found to show that alternative inhaler devices are more effective than standard pressurised metered dose inhalers for delivering acting ₂ agonist bronchodilators in asthma. Pressurised metered dose inhalers remain the most cost effective delivery devices.

What is already known on this topic Many different inhaler devices are available for administration of short acting 2 agonists in asthma Current guidelines for their use are inconsistent and not evidence based What this study adds This systematic review found no evidence that alternative inhaler devices are more effective than pressurised metered dose inhalers for administering inhaled 2 agonist bronchodilators Pressurised metered dose inhalers (or the cheapest inhaler device) should be used as first line treatment in all patients with stable asthma who require 2 agonists