Twohig H, Franklin L, Carroll W, Corp N, Jackson E, Mallen C, Ruan B, Yapp L, Der Windt DV, Smith J. Paediatr Respir Rev. 2025 Apr 16:S1526-0542(25)00036-3. doi: 10.1016/j.prrv.2025.04.005.
Abstract
Background
Dry powder inhalers (DPIs) are a lower-carbon option than pressurised metered dose inhalers (pMDIs). However, DPIs require a forceful inhalation to achieve good lung deposition and there is uncertainty as to whether younger children can effectively use DPIs for maintenance treatment or rely upon them during exacerbations.
Methods
We searched electronic databases to identify randomised trials of children with asthma receiving treatment delivered via DPI, either for maintenance treatment (children ≤ 12 years) or for an acute exacerbation (participants up to age 18). Screening and data extraction were carried out by two reviewers. Risk of bias (RoB) assessment was made using the Cochrane RoB2 tool. Findings were narratively synthesised and a modified GRADE approach was taken to summarise the strength of evidence.
Results
27 studies were included. 20 addressed maintenance treatment in children ≤ 12 years although only 4 compared the same treatment delivered via pMDI to DPI. All found no difference in efficacy between the device types (high certainty evidence). Other studies provided weaker, indirect evidence supporting this finding. 7 studies considered acute asthma in hospital/emergency settings. All reported no difference in efficacy between device types but certainty of evidence was low due to high RoB and clinical and methodological heterogeneity.
Conclusion
There are few studies directly comparing treatment via DPI/pMDI for asthma in children. Comparative studies suggest that for children who can use both DPI/pMDI, the devices are equal in efficacy for maintenance treatment in children ≤ 12 years but high-quality evidence is lacking regarding their use during acute exacerbations. This review did not find sufficient evidence to identify a lower age at which DPIs can start being used.
Educational aims
The reader will:
- Be provided with a synthesis of the evidence to date on clinical effectiveness of dry powder inhalers in treatment of asthma in children in two areas of clinical uncertainty – maintenance treatment in children aged 12 and under and treatment of exacerbations.
- Understand that DPIs and pMDIs have equivalent clinical effectiveness for maintenance treatment in children aged 12 and under but choice of inhaler device should be made after individual assessment.
- Understand that there is a lack of evidence on the use of DPIs in early or mild exacerbations but that future studies of AIR / MART regimes will help address this on-going uncertainty.
- Recognise that there is insufficient evidence to set a lower age for DPI use.