Home-made spacers for bronchodilator therapy in children with acute asthma: a randomised trial

Background A metered-dose inhale, (MDI) with spacer is the best way to deli ver bronchodilator therapy for treatment of acute asthma, In developing cou ntries, commercially produced spacers are generally unavailable or too cost ly. We tested the efficacy of home-made spacers (500 mL plastic bottle, pol ystyrene cup) compared with a conventional spacer for delivery of a beta(2) agonist via MDI for children with acute asthma. Methods We studied children aged 5 to 13 years with acute asthma, stratifie d into those with mild airways obstruction (peak expiratory flow [PEF] 60-7 9% of predicted value) or moderate to severe airways obstruction (PEF 20-59 % of predicted value). A beta(2) agonist (fenoterol hydrobromide) was given via MDI and one of four randomly assigned spacers (conventional spacer, se aled 500 mL plastic bottle, unsealed 500 mt bottle, 200 mt polystyrene cup) . Clinical score, pulmonary function tests, and oximetry were recorded at b aseline and 15 min after treatment. If a second bronchodilator treatment wa s needed, nebulised fenoterol was given and the assessment repeated 15 min later. Primary outcome measures were changes in clinical score and pulmonar y function, and need for and response to nebulisation. Findings 88 children were eligible for study, In 44 children with moderate to severe airways obstruction, a cup gave significantly less bronchodilatio n (median increase in: forced expiratory volume in 1 s [FEV1] 0%; PEF 12%) compared with the conventional spacer (37%; 59%), sealed bottle (33%; 36%), or unsealed bottle (18%; 21%, p<0.05 for difference between groups). Nebul isation was required by ten of 11 who had used a cup, nine of 11 who had us ed an unsealed bottle, eight of 11 who had used a sealed bottle, and only f our of 11 who had used a conventional spacer. After nebulisation, improveme nt in FEV1 (15.5%) and PEF (26%) was more marked in children who had used a cup than in those who had used a conventional spacer (5.5% FEV1; 4% PEF), seared bottle (3%; 0%), or unsealed bottle (7%; 9%), For 44 children with m ild airways obstruction, response to bronchodilator was similar for all spa cers and need for nebulisation was not associated with use of a particular spacer. Interpretation A conventional spacer and sealed 500 mL plastic bottle produ ced similar bronchodilation, an unsealed bottle gave intermediate improveme nt in lung function, and a polystyrene cup was least effective as a spacer for children with moderate to severe airways obstruction. Use of bottle spa cers should be incorporated into guidelines for asthma management in develo ping countries.