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Plymouth Health Community
NICE Guidance
Implementation Group
Asthma inhalers for routine
treatment of chronic
asthma in older children
(aged 5 - 15 years)
Miss Faye Doris
University of Plymouth
The National Institute of
Clinical Excellence
Clinical Guidelines
 View arrived at after careful
consideration of the available
evidence
 Health professionals are
expected to consider these
when making a clinical
judgement
The National Institute of
Clinical Excellence
Clinical Guidelines
 do not ‘override the individual
responsibility of health
professionals, to make
appropriate decisions in the
circumstances of the
individual patient, in
consultation with the patient
and or their guardian or
carer’.
Previous Guidance:
management of asthma in
adults and children
 British Thoracic Society (BTS)
guideline issued in 1997 was
the most commonly used in
the UK
 Not explicitly evidenced based
 largely considered the
management of asthma in
adults and older children
Previous Guidance: British
Thoracic Society Guidance
Contd.
 Principles for selection of
devices stated
 Recommendations about
specific devices not made
The Appraisal Process
 Examination of the evidence
on the clinical effectiveness
and cost effectiveness of
inhaler devices
 Stakeholder consultations
The Appraisal Process:
Systematic Reviews
A review of research-based
evidence on a topic in which
the evidence has been
systematically identified,
appraised and summarised
according to pre determined
criteria.
Randomised Controlled
Trials
 A trial in which subjects are
randomly assigned to either a
group receiving an
intervention that is being
tested or control group
receiving an alternative or no
intervention. The results
compare the results of
different groups.
Clinical effectiveness:
Systematic Review
 The specificity of device and
drug effect meant one drug in
one device could not be
compared to other drugs
 Limited evidence found in
relation to quantity and
quality
Clinical effectiveness:
Systematic Review
 Studies claiming to
demonstrate equivalence
were unable to do so and
some studies used
inappropriate dose
comparators
 Available evidence therefore
limited and poor
Delivery of bronchodilatorsthe evidence
 23 studies examined
 Some used inappropriate
dosing schedules, which may
have biased their findings
 Some included a high
proportion of adults
 Some were small or included
few children
Delivery of anti-flammatory
drugs- the evidence
 A number of studies were
examined
 The quality of the studies was
variable either in relation to
number of children or the use
of the design
 Well designed studies did not
report on differences in
effectiveness between devices
CFC- free devices - the
evidence
 No evidence of difference in
CFC containing or CFC free
devices
 Although some reports of
higher deposition of cortico
steroids in HFA inhalers
Other influences on
effectiveness
 31 studies on ease of use,
preference or compliance
 quality generally poor, small
numbers, some included
adults
 Only 11 were RCTs
Other influences on
effectiveness: Key finding
 Good individual (verbal)
instruction was the key to
good inhaler technique
 Two studies found that above
age 5 or 6 years this was so
regardless of device
Cost effectiveness
 No robust cost effectiveness
or utility studies examining
the use of inhalers in children
aged 5 - 15 years were
identified in the systematic
review
Consideration and
Conclusions
 ‘The available evidence failed
to distinguish adequately
between devices to suggest
advantage in clinical
effectiveness for one single
delivery system’
Consideration and
Conclusions
 Limited evidence supports the
use of press and breathe
pMDIs with large volume
spacers compared to press
and breathe devices alone in
the delivery of
bronchodilators.
Consideration and
Conclusions
 Economic analysis suggests
that no device should be
excluded on grounds of cost
effectiveness
Further research and
implementation
 In view of the lack of robust
evidence the need for further
good quality research is
identified
 Good practice guidance is
however provided to enable
use of the limited evidence
available.
Plymouth Health Community
NICE Guidance
Implementation Group
Asthma inhalers for routine
treatment of chronic
asthma in older children
(aged 5 - 15 years)
Miss Faye Doris
University of Plymouth