Spacer Use for Toddlers With Asthma: Not All Are Created Equal

Source: Csonka P, Ruuska-Loewald T, Hämynen I, et al. Valved holding chambers in young children with acute wheezing: a randomized clinical trial. JAMA Pediatr. 2026;180(5):567-574; doi: 10.1001/jamapediatrics.2025.6479.Investigators from multiple institutions in Finland conducted a randomized clinical trial comparing 2 valve holding chambers (VHCs) used to deliver inhalation medications such as albuterol in the treatment of young children with acute wheezing. Both VHCs are commercially available. One VHC (VHC-high) delivered a high dose of medication during in vitro tests, and the other (VHC-low) delivered a lower dose and is the most commonly used VHC in Finland. Study participants were children 6–48 months old presenting with acute wheezing and a Respiratory Distress Assessment Instrument (RDAI) score ≥6 to 1 of 3 emergency departments or 1 primary care clinic in Finland. At enrollment, participants were randomized to the VHC-high or VHC-low groups. All patients received albuterol (0.6 mg per treatment) delivered via the assigned VHC. Three treatments at 20-minute intervals were provided to all children, with a fourth treatment administered at the discretion of the treating physician. The primary outcomes were posttreatment RDAI scores, change in RDAI score from baseline, and proportion of patients in each group with a clinically meaningful reduction in RDAI score (defined as ≥2 points). Secondary outcomes included hospitalization for wheezing and need for a fourth dose of albuterol. These outcomes were compared in participants in the 2 treatment groups.Data were analyzed on 80 children with a mean age 23.1 months; 40 participants were assigned to each treatment group. At baseline, the mean RDAI score was 11.3 ±3.0 for those assigned to the VHC-high group and 9.9 ±3.0 for children randomized to the VHC-low group. Posttreatment, RDAI scores were significantly lower for patients in the VHC-high group than those in the VHC-low group (2.7 ±2.1 vs 6.8 ±3.6; difference, -4.1; 95% confidence interval CI, -5.4, -2.7). Those in the VHC-high treatment group also had a significantly greater decrease in RDAI score from baseline (mean change, -8.6 ±3.0 vs -3.2 ±3.7; difference, -5.4; 95% CI, -6.9, -3.9); 98% of participants randomized to VHC-high had a decrease in RDAI score ≥2 points, compared to 70% of those randomized to VHC-low (difference, 28%; 95% CI, 14, 44). Among those in the VHC-high group, 8 (20%) were hospitalized vs 20 (50%) children in the VHC-low group (difference, 30%; 95% CI, 9.2, 49). A fourth treatment with albuterol was provided to 58% and 80%, respectively, of patients in the VHC-high and VHC-low groups (difference, 22%; 95% CI, 2.1, 41).The authors conclude that administration of albuterol to young children with wheezing via a VHC with high drug delivery was more effective than use of a VHC with lower drug delivery.Dr Goyal has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.For infants and toddlers under 4 years of age, the prevalence of asthma is approximately 2.6%.1 Diagnosis in these youngest asthma patients often is subjective, and clinical practices are inconsistent, yet compared to older children, they have the highest rates of hospitalization and ED utilization.2,3For more than 2 decades, it has been well established that metered-dose inhaler (MDI) use with a VHC—often referred to as a spacer—is at least as effective as a nebulizer for treatment of asthma exacerbations in infants and toddlers. (See AAP Grand Rounds. 2003;95:49-50.)4 Counseling on the importance of VHCs and techniques for proper use is considered essential. However, there is scant evidence for the clinical effectiveness of 1 brand of VHC compared with another, and in primary care settings, various brands typically are considered functionally equivalent.In the current study, the investigators directly compared 2 VHCs, Optichamber Diamond (high-dose in in-vitro testing) and Babyhaler (low-dose in in-vitro), for young children (under 48 months) presenting with acute wheeze.5 Those randomized to the Optichamber Diamond had greater improvement in respiratory scores and lower admission rates. While the Babyhaler is not commercially available in the US, several other commonly used, FDA-cleared products also are considered low-dose based on in-vitro testing. The investigators concluded that asthma care guidelines should incorporate guidance on specific VHCs.The specific type of VHC (ie, higher drug delivery) impacts the effectiveness of asthma treatment with MDIs for young children.The differences in outcomes between the 2 treatment groups are striking and suggest that we should be paying a lot more attention to the type of VHC used and its ability to provide the desired dose of medication effectively.