Utility of a Mask with a Spacer to Deliver the Contents of a Metered Dose Inhaler.

To the Editor:

We read with interest the article by Volerman and colleagues published in AnnalsATS, in which she has brought out the inconsistencies in the recommendations concerning the use of spacers and masks in children on therapy with metered dose inhalers aptly (1). She also goes on to discuss how some clinicians are continuing to recommend the use of masks with spacers based on their beliefs in children beyond the recommended ages. She discusses the need for focused research in these areas, which is a welcome move. In this regard, we would like to share our experiences concerning the use of masks along with spacers or valved holding chambers in children beyond the recommended age of 4 or 5 years. We personally recommend the use of masks in at least three settings even if the child is beyond the recommended age of 4 or 5 years.

First, in children with nighttime symptoms, it is easier to administer short-acting β-agonist puffs for quick relief of symptoms using a spacer with the face mask, as the child need not be awakened to take the medication puffs by their own voluntary efforts. Second, in children who have concomitant allergic rhinitis and asthma and are prescribed inhaled corticosteroids (ICS) as metered dose inhalers, using the mask to deliver the ICS might obviate the need for having separate inhaled nasal steroids for control of allergic rhinitis in addition to the controller (ICS) prescribed for asthma. Third, in children who have intellectual disability and are not able to understand or follow through on instructions, masks with spacers may be helpful in using the device effectively.

Apart from the issue regarding the use of masks, recommendations regarding the use of rotahalers are also needed, as there seems to be a wide variation in their use across the world. We prefer rotahalers in children aged 5 and above, and our preference is driven by economic constraints as our hospital provides rotahalers and rotacaps free of cost to all patients. More evidence is needed in these areas, as there are not enough good quality randomized trials to inform evidence concerning the use of masks and rotahalers in the above situations.