A provider asks you if there's anything you can recommend to a patient to help maximize the delivery of inhaled steroids in an asthmatic patient. The provider has already given the patient a spacer and had him instructed by the patient education nurse on proper use of a metered dose inhaler (MDI) plus spacer and correct inhalation technique.

*** THANKS to COL (Dr.) John Mitchell for his input for this Pearl ***

Yes. Consider the following to make your new spacer more effective in delivering drug to the lungs.

Problematic 'static cling' (electrostatic charge) of inhaled aerosol medications to the interior of a towel-dried device is extremely well described in Pulmonary literature years ago.  Priming the spacer with several puffs from the MDI has been discussed and is likely what happens with most patients.  The recommendation is to soak the devices in warm soapy water,  then rinse it with a not-too forceful jet of water, then to shake the droplets out, and then let the device parts air dry.  For new devices, you can just not worry about it or just use some aerosol in the course of therapy. One abstract used 20 puffs into the new spacer. Metal spacers are not susceptible to static charge.

One study stated that electrostatic charge in plastic spacers may reduce lung delivery of inhaled meds by more than two fold. Another study quantifying the benefit of detergent treated spacers estimated the increase in small particle output from the spacer at 33-41%. The effect of the detergent washing appeared to last about 4 weeks.

It is in the PDR and package insert - CLEANSE THE INHALER THOROUGHLY AND FREQUENTLY. Remove the metal canister and cleanse the plastic case and cap by rinsing thoroughly in warm running water, at least once a day. Besides cleaning out any residual inhalant/drug particles, the anionic soap may help decrease/eliminate any electrostatic cling.

References:

- Wildhaber JH, et al. Br J Clin Pharmacol 2000;50:277-80.

- Kenyon CJ, et al. Eur Respir J. 1998;11:606-10.

- Wildhaber JH, et al. Eur Respir J. 1996;9:11943-6.

- Pierart F, et al. Eur Respir J. 1999;13:673-8.

- Anhoj J, et al. Br J Clin Pharmacol 1999;47;333-6.

- Chuffart AA, et al. Swiss Med Wkly 2001;131:14-8.

- Bennett FS, et al. Drug Dev Ind Pharm 1999;25:99-1033.

- Wildhaber JH, et al. Pediatr Pulmonol 2000;29:289-93.