title: Pressurised metered-dose inhalers versus all other hand-held inhalers devices to deliver bronchodilators for chronic obstructive pulmonary disease.
abstract: BACKGROUND
  Bronchodilator therapy for COPD may be delivered by a number of different inhaler devices.
  
  
  OBJECTIVE
  To determine the efficacy of pressurised metered dose inhalers (pMDI) compared to any other handheld inhaler device for the delivery of bronchodilators in non-acute COPD.
  
  
  METHODS
  The Cochrane Collaboration, Asthma and Wheeze Randomised Controlled Clinical Trials register was searched for studies. The UK pharmaceutical companies who manufacture inhaled COPD medication were also contacted.
  
  
  METHODS
  Two reviewers independently reviewed the results of computerised search and any potentially relevant articles were obtained in full.
  
  
  METHODS
  One reviewer extracted details of each trial and a second reviewer checked all extracted data. Dichotomous outcomes such as exacerbation rate were assessed using relative risk, with 95% confidence interval (CI).
  
  
  RESULTS
  Fourteen studies appeared potentially relevant but only three studies (61 patients) met the entry criteria. Two studies compared a dry powder device (Turbuhaler or Rotahaler) with a pMDI for beta2-agonist delivery, and one (36 patients cross-over design) the Respimat (soft mist device for ipratropium) vs a pMDI. For the Turbuhaler and Rotahaler, none of the reported outcome measures were significantly different. The Rotahaler study used a high and low dose of medication with or without large volume spacer. The study using the Respimat showed significant increases in FEV1 when compared to a pMDI (difference in change from base line 70 ml, 95% CI 10, 130 ml). The effect on change in FVC was of similar size. There were no differences between these two devices for any other reported outcomes. Although none of the included studies required prior patient ability to use any of the inhalers (and no study mentioned device training), it was assumed that all patients randomised into the study would have undergone training in use of the study inhalers and were capable of using those devices.
  
  
  CONCLUSIONS
  In patients with stable COPD, pMDI produced similar outcomes to a dry powder device for delivering beta2-agonists, but the very small number of studies and included patients does not permit firm conclusions to be drawn. The soft mist device for ipratropium was more effective than a pMDI, but the data come from one small study. There need to be further well designed randomised controlled trials to define the role of inhaler devices using bronchodilators in stable COPD.
authors.affiliation: Department of Physiological Medicine, St George's Hospital Medical School, Level 0, Jenner Wing, Cranmer Terrace, London, UK, SW17 0RE. fram@sghms.ac.uk
authors.forename: F S
authors.initials: FS
authors.lastname: Ram
authors.forename: D M
authors.initials: DM
authors.lastname: Brocklebank
authors.forename: M
authors.initials: M
authors.lastname: Muers
authors.forename: J
authors.initials: J
authors.lastname: Wright
authors.forename: P W
authors.initials: PW
authors.lastname: Jones
mesh_terms: D000322:Adrenergic Agonists / Q000008:administration & dosage; D001993:Bronchodilator Agents / Q000008:administration & dosage*; D006801:Humans; D009330:Nebulizers and Vaporizers; D029424:Pulmonary Disease, Chronic Obstructive / Q000188:drug therapy*; D016032:Randomized Controlled Trials as Topic
chemical_list: D000322:Adrenergic Agonists; D001993:Bronchodilator Agents