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

Abstract

Objectives: To determine the clinical effectiveness of pressurised metered dose inhalers compared with other hand held inhaler devices for delivering short acting beta(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 beta(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 beta(2 )agonist bronchodilators in asthma. Pressurised metered dose inhalers remain the most cost effective delivery devices.

Figures

Figure 1

QUORUM trial flow results

Figure 2

Forced expiratory volume in one second values for patients in trials comparing pressurised metered dose inhalers with Turbohaler

Figure 3

Example funnel plot for 31 trials (1290 participants) with data on forced expiratory flow volume in one second for pressurised metered dose inhaler and all other inhaler devices combined using standardised mean difference