Abstract
Spacer devices are attachments to the mouthpieces of pressurised metered dose inhalers (pMDIs), and range from tube spacers with a volume of <50mL to holding chambers with a volume of 750mL. Compared with a pMDI alone, spacers minimise coordination difficulties, reduce oropharyngeal deposition and often increase lung deposition. Spacers may not improve the clinical effect in patients able to use a pMDI properly, but may allow maintenance dosages of bronchodilators and corticosteroids to be reduced. Correct use of spacer devices is important, especially achieving control over electrostatic charge accumulation on the walls of plastic devices. In patients with severe acute asthma or severe chronic obstructive pulmonary disease, a pMDI plus large volume spacer may be a viable alternative to a nebuliser for delivering large bronchodilator doses. Although the addition of a spacer to every pMDI would not be justified, the use of large volume spacers has been recommended for any inhaled asthma drug in young children, and as a means of reducing systemic bioavailability of inhaled corticosteroids in adults and children alike.
Similar content being viewed by others
Notes
1 The use of trade names is for product identification purposes only and does not imply endorsement.
References
Woodcock A, Acerbi D, Poli G. Modulite technology: pharmacodynamic and pharmacokinetic implications. Respir Med 2002; 96 (D Suppl.): S9–S15
Newman SP. Devices for inhaling medications. In: Clark TJH, Lee T, Godfrey S, et al., editors. Asthma. 4th ed. London: Edward Arnold Limited, 2000: 329–54
Partridge MR, Woodcock AA, Sheffer AL, et al. Chlorofluorocarbon-free inhalers: are we ready for the change?. Eur Respir J 1998; 11: 1006–8
Pedersen S, Frost L, Arnfred T. Errors in inhalation technique and efficiency in inhaler use in asthmatic children. Allergy 1986; 41: 118–24
Thiel CG. From Susie’s question to CFC free: an inventor’s perspective on forty years of MDI development and regulation. In: Dalby RN, Byron PR, Farr SJ, editors. Respiratory drug delivery V. Buffalo Grove (IL): Interpharm Press, 1996: 115–23
Freigang B. New method of beclomethasone aerosol administration to children under 4 years of age. CMAJ 1977; 117: 1308–9
König P. Spacer devices used with metered dose inhalers: breakthrough or gimmick?. Chest 1985; 88: 276–84
Newman SP, Newhouse MT. Effect of add-on devices for aerosol drug delivery: deposition studies and clinical aspects. J Aerosol Med 1996; 9: 55–70
Woodcock A, Kendall J, Humberstone A, et al. The blo-bag, a disposable spacer. Postgrad Med J 1984; 60 (1 Suppl.): 37–9
El-Kassimi FA. ’Aerosol-in-bag’ administration of inhaled bronchodilators. Eur J Respir Dis 1987; 70: 234–8
Dolovich MB. Proceedings of Drug Information Association Spacer Device Symposium; 1995 Mar 27–28; Boston. Horsham (PA): Drug Information Association, 1995
Kraemer R, Frey U, Sommer CW, et al. Short-term effect of albuterol, delivered via a new auxiliary device, in wheezy infants. Am Rev Respir Dis 1991; 144: 347–51
Bisgaard H. Automatic actuation of a dry powder inhaler into a non-electrostatic spacer. Am J Respir Crit Care Med 1998; 157: 518–21
O’Callaghan C, Lynch J, Cant M, et al. Improvement in sodium cromoglycate delivery from a spacer device by use of an antistatic lining, immediate inhalation and avoiding multiple actuations of drug. Thorax 1993; 48: 603–6
Chrystyn H. Methods to identify drug deposition in the lungs following inhalation. Br J Clin Pharmacol 2001; 51: 289–99
Agertoft L, Pedersen S. Influence of spacer device on drug delivery to young children with asthma. Arch Dis Child 1994; 71: 217–20
Snell NJC, Ganderton D. Assessing lung deposition of inhaled medications. Respir Med 1999; 93: 123–33
Richards JC, Hirst PH, Pitcairn GR, et al. Deposition and pharmacokinetics of flunisolide delivered from pressurized inhalers containing non-CFC and CFC propellants. J Aerosol Med 2001; 14: 197–208
Hirst PH, Pitcairn GR, Richards JC, et al. Deposition and pharmacokinetics of an HFA formulation of triamcinolone acetonide delivered by pressurized metered dose inhaler. J Aerosol Med 2001; 14: 155–65
Dolovich MB, Ruffin R, Corr D, et al. Clinical evaluation of a new demand-inhalation MDI aerosol delivery device. Chest 1983; 84: 36–41
Hardy JG, Jasuja AK, Frier M, et al. A small volume spacer for use with a breath-operated pressurised metered dose inhaler. Int J Pharm 1996; 142: 129–33
Vidgren MT, Paronen P, Karkkainen A, et al. Effect of extension devices on drug deposition from inhalation aerosols. Int J Pharm 1987; 39: 107–12
Barry PW, O’Callaghan C. Inhalational drug delivery from seven different spacer devices. Thorax 1996; 51: 835–40
Barry PW, O’Callaghan C. The optimum size and shape of spacer devices for inhalational therapy. J Aerosol Med 1995; 8: 303–5
Matthys H. Inhalation delivery of asthma drugs. Lung 1990; 168 Suppl.: 645–52
Toogood JH, Baskerville J, Jennings B, et al. Use of spacers to facilitate inhaled corticosteroid treatment in asthma. Am Rev Respir Dis 1984; 129: 723–9
Newman SP, Talaee N, Clarke SW. Salbutamol aerosol delivery with the Rondo spacer. Acta Ther 1991; 17: 49–58
O’Callaghan C, Barry PW. Spacer devices in the treatment of asthma. BMJ 1997; 314: 1061–2
Bloomfield P, Crompton GK, Winsey NJP. A tube spacer to improve inhalation of drugs from pressurised aerosols. BMJ 1979; 2: 1479
Lee H, Evans HE. Evaluation of inhalation aids of metered dose inhalers in asthmatic children. Chest 1987; 91: 366–9
Crimi N, Palermo F, Cacopardo B, et al. Bronchodilator effect of Aerochamber and InspirEase in comparison with metered dose inhaler. Eur J Respir Dis 1987; 71: 153–7
Godden DJ, Crompton GK. An objective assessment of the tube spacer in patients unable to use a conventional pressurised aerosol efficiently. Br J Dis Chest 1981; 75: 165–8
Pedersen S. Aerosol treatment of bronchoconstriction in children, with or without a tube spacer. N Engl J Med 1983; 308: 1328–30
British Thoracic Society. British guideline on the management of asthma. Thorax 2003; 58 Suppl. I: 1–97
McCarthy TP. Nebulised budesonide in severe childhood asthma. Lancet 1989; I: 379–80
Bisgaard H, Munck SL, Nielsen JP, et al. Inhaled budesonide for treatment of recurrent wheezing in early childhood. Lancet 1990; 336: 649–51
Keeley D. Large volume plastic spacers in asthma. BMJ 1992; 305: 598–9
Barnes PJ, Pedersen S, Busse WW. Efficacy and safety of inhaled corticosteroids: new developments. Am J Respir Crit Care Med 1998; 157: S1–S53
Derendorf H. Pharmacokinetic and pharmacodynamic properties of inhaled corticosteroids in relation to efficacy and safety. Respir Med 1997; 91 (A Suppl.): 22–8
Brown PH, Blundell G, Greening AP, et al. Do large volume spacers reduce the systemic effects of high dose inhaled corticosteroids?. Thorax 1990; 45: 736–9
British Asthma Guidelines Coordinating Committee. British Guidelines on asthma management: 1995 review and position statement. Thorax 1997; 52: S1–S24
Noseda A, Yernault JC. Sympathomimetics in acute severe asthma: inhaled or parenteral, nebuliser or spacer. Eur Respir J 1989; 2: 377–82
Laursen LC, Munch EP, Weeke E, et al. Comparison of a 750ml spacer and a nebulizer in domiciliary treatment of severe chronic asthma with terbutaline. Eur J Respir Dis 1983; 64: 498–503
Colacone A, Marc A, Wolkove N, et al. A comparison of albuterol administered by metered dose inhaler (and holding chamber) or wet nebuliser in acute asthma. Chest 1993; 104: 835–41
Chrystyn H. Pharmacokinetic methods to determine the lung deposition of nebulized drugs. Eur Respir Rev 2000; 10: 228–31
O’Callaghan C, Barry PW. The science of nebulised drug delivery. Thorax 1997; 52 Suppl. 2: S31–44
Fok TF, Lam K, Ng PC, et al. Delivery of salbutamol to nonventilated preterm infants by metered dose inhaler, jet nebuliser and ultrasonic nebuliser. Eur Respir J 1998; 12: 159–64
Chou KJ, Cunningham SJ, Crain EF. Metered dose inhalers with spacers vs nebulisers for paediatric asthma. Arch Pediatr Adolesc Med 1995; 149: 201–5
Teirlinck TJPM. Nebulizers in home health care: additional requirements with regard to product standardization. Eur Respir Rev 2000; 10(72): 220–3
Cates CCJ, Bara A, Crilly JA, et al. Holding chambers versus nebulisers for beta-agonist treatment of acute asthma. In: The Cochrane Library, issue 1. Chichester: John Wiley & Sons Ltd, 2004.
Dewar AL, Stewart A, Cogswell JJ, et al. A randomised controlled trial to assess the relative benefits of large volume spacers and nebulisers to treat acute asthma in hospital. Arch Dis Child 1999; 80: 421–3
Gleeson JGA, Price JF. Nebuhaler technique. Br J Dis Chest 1988; 82: 172–4
Green CP, Price JF. Bronchodilator effect of salbutamol via the volumatic in children. Respir Med 1991; 85: 325–6
Newman SP, Woodman G, Morén F, et al. Bronchodilator therapy with nebuhaler: how important is the delay between firing the dose and inhaling?. Br J Dis Chest 1987; 82: 262–7
Dewsbury NJ, Kenyon CJ, Newman SP. The effect of handling techniques on electrostatic charge on spacer devices: a correlation with in vitro particle size analysis. Int J Pharm 1996; 137: 261–4
Pierart F, Wildhaber JH, Vrancken I, et al. Washing plastic spacers in household detergent reduces electrostatic charge and greatly improves delivery. Eur Respir J 1999; 13: 673–8
Kenyon CJ, Thorsson L, Borgström L, et al. The effects of static charge in spacer devices on glucocorticosteroid aerosol deposition in asthmatic patients. Eur Respir J 1998; 11: 606–10
Wildhaber JH, Waterer GW, Hall GL, et al. Reducing electrostatic charge on spacer devices and bronchodilator response. Br J Clin Pharmacol 2000; 50: 277–80
Barry PW, O’Callaghan C. The output of budesonide from spacer devices assessed under simulated breathing conditions. J Allergy Clin Immunol 1999; 104: 1205–10
Thorsson L, Kenyon CJ, Newman SP, et al. Lung deposition of budesonide in asthmatics: a comparison of different formulations. Int J Pharm 1998; 168: 119–27
Baum EA. Design, development and testing of a new breath actuated inhaler. In: Inspiration: developments in inhalation therapy. Oxford: The Medicine Publishing Foundation, 1989: 21–30
Lenney J, Innes JA, Crompton GK. Inappropriate inhaler use: assessment of use and patient preference of seven inhalation devices. Respir Med 2000; 94: 496–500
Newman SP, Weisz AWB, Talaee N, et al. Improvement of drug delivery with a breath actuated pressurised aerosol for patients with poor inhaler technique. Thorax 1991; 46: 712–6
Pedersen S, Mortensen S. Use of different inhalation devices in children. Lung 1990; 168 Suppl.: 653–7
Newman SP, Clarke SW. Bronchodilator delivery from Gentlehaler, a new low-velocity pressurized aerosol inhaler. Chest 1993; 103: 1442–6
Mohsen N. pMDI aerosol momentum manipulation and biotargeted delivery. In: Dalby RN, Byron PR, Peart J, et al., editors. Respiratory drug delivery VIII. Raleigh (NC): Davis Horwood, 2002: 593–97
Newnham DM, McDevitt DG, Lipworth BJ. Comparison of the extrapulmonary beta-2 adrenoceptor responses and pharmacokinetics of salbutamol metered dose-inhaler and modified actuator device. Br J Clin Pharmacol 1993; 36: 445–50
Newman SP, Steed KP, Hooper G, et al. Improved targeting of beclomethasone dipropionate (250mg metered dose inhaler) to the lungs of asthmatics with the Spacehaler. Respir Med 1999; 93: 424–31
Newman SP, Steed KP, Reader SJ, et al. Efficient delivery to the lungs of flunisolide from a new portable hand-held multidose nebuliser. J Pharm Sci 1996; 85: 960–4
Leach CL, Davidson PJ, Boudreau RJ. Improved airway targeting with the CFC-free HFA-beclomethasone metered-dos inhaler compared with CFC-beclomethasone. Eur Respir J 1998; 12: 1346–53
Busse WW, Brazinsky S, Jacobson K, et al. Efficacy response of inhaled beclomethasone dipropionate in asthma is proportional to dose and is improved by formulation with a new propellant. J Allergy Clin Immunol 1999; 104: 1215–22
Pritchard JN. The influence of lung deposition on clinical response. J Aerosol Med 2001; 14 (Suppl. 1): S19–26
Newman SP, Busse WW. Evolution of dry powder inhaler design, formulation and performance. Respir Med 2002; 96: 293–304
Zierenberg B, Eicher J, Dunne S, et al. Boehringer Ingelheim nebulizer BINEB: a new approach to inhalation therapy. In: Dalby RN, Byron PR, Farr SJ, editors, Respiratory drug delivery V. Buffalo Grove (IL): Interpharm Press, 1996: 187–93
Hochrainer D, Hölz H. Comparison of cloud velocities delivered from Respimat soft mist inhaler or MDIs [abstract]. J Aerosol Med 2001; 14: 386
Progress. National Asthma Campaign Newsletter, August 200
Pedersen S. Delivery systems in children. In: Barnes PJ, Grunstein MM, Leff AR, et al., editors. Asthma. Philadelphia (PA; Lippincott-Raven, 1997: 1915–29
Acknowledgements
The author has provided no information on sources of funding or on conflicts of interest directly relevant to the content of this study.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Newman, S.P. Spacer Devices for Metered Dose Inhalers. Clin Pharmacokinet 43, 349–360 (2004). https://doi.org/10.2165/00003088-200443060-00001
Published:
Issue Date:
DOI: https://doi.org/10.2165/00003088-200443060-00001