What the pulmonary specialist should know about the new inhalation therapies

A collaboration of multidisciplinary experts on the delivery of pharmaceutical aerosols was facilitated by the European Respiratory Society (ERS) and the International Society for Aerosols in Medicine (ISAM), in order to draw up a consensus statement with clear, up-to-date recommendations that enable the pulmonary physician to choose the type of aerosol delivery device that is most suitable for their patient. The focus of the consensus statement is the patient-use aspect of the aerosol delivery devices that are currently available. The subject was divided into different topics, which were in turn assigned to at least two experts. The authors searched the literature according to their own strategies, with no central literature review being performed. To achieve consensus, draft reports and recommendations were reviewed and voted on by the entire panel. Specific recommendations for use of the devices can be found throughout the statement. Healthcare providers should ensure that their patients can and will use these devices correctly. This requires that the clinician: is aware of the devices that are currently available to deliver the prescribed drugs; knows the various techniques that are appropriate for each device; is able to evaluate the patient's inhalation technique to be sure they are using the devices properly; and ensures that the inhalation method is appropriate for each patient.

[1]  T. Klassen,et al.  Nebulised hypertonic saline solution for acute bronchiolitis in infants. , 2017, The Cochrane database of systematic reviews.

[2]  R. Mehta,et al.  Bioavailability of inhaled fluticasone propionate via chambers/masks in young children , 2011, European Respiratory Journal.

[3]  David Price,et al.  Choosing inhaler devices for people with asthma: current knowledge and outstanding research needs. , 2010, Respiratory medicine.

[4]  David Price,et al.  Not all asthma inhalers are the same: factors to consider when prescribing an inhaler. , 2009, Primary care respiratory journal : journal of the General Practice Airways Group.

[5]  A. Boner,et al.  Medicines used in respiratory diseases only seen in children , 2009, European Respiratory Journal.

[6]  D. Touw,et al.  Inhaled medication and inhalation devices for lung disease in patients with cystic fibrosis: A European consensus. , 2009, Journal of cystic fibrosis : official journal of the European Cystic Fibrosis Society.

[7]  H. Chrystyn,et al.  What you need to know about inhalers and how to use them , 2009 .

[8]  M. Levy,et al.  The ADMIT series--issues in inhalation therapy. 3) Mild persistent asthma: the case for inhaled corticosteroid therapy. , 2009, Primary care respiratory journal : journal of the General Practice Airways Group.

[9]  D. Geller,et al.  New aerosol delivery devices for cystic fibrosis. , 2009, Respiratory care.

[10]  M. Broeders,et al.  The ADMIT series--issues in inhalation therapy. 2. Improving technique and clinical effectiveness. , 2009, Primary care respiratory journal : journal of the General Practice Airways Group.

[11]  D. Price,et al.  Inhaled corticosteroids for asthma: impact of practice level device switching on asthma control , 2009, BMC pulmonary medicine.

[12]  Jeremy C Johnson,et al.  Aerosol delivery of recombinant human DNase I: in vitro comparison of a vibrating-mesh nebulizer with a jet nebulizer. , 2008, Respiratory care.

[13]  L. Corbetta,et al.  Achieving asthma control: the key role of inhalers , 2008 .

[14]  P. Haidl,et al.  Handling of and preferences for available dry powder inhaler systems by patients with asthma and COPD. , 2008, Journal of aerosol medicine and pulmonary drug delivery.

[15]  Chris Corrigan,et al.  Effect of incorrect use of dry powder inhalers on management of patients with asthma and COPD. , 2008, Respiratory medicine.

[16]  P. Rees,et al.  Use of dry powder inhalers in COPD , 2007, International journal of clinical practice.

[17]  Karen A Robinson,et al.  Cystic fibrosis pulmonary guidelines: chronic medications for maintenance of lung health. , 2007, American journal of respiratory and critical care medicine.

[18]  L. Fabbri,et al.  Beclomethasone/formoterol vs fluticasone/salmeterol inhaled combination in moderate to severe asthma , 2007, Allergy.

[19]  J. Wildhaber,et al.  Facemasks and aerosol delivery in vivo. , 2007, Journal of aerosol medicine : the official journal of the International Society for Aerosols in Medicine.

[20]  G. Smaldone,et al.  Facemask design, facial deposition, and delivered dose of nebulized aerosols. , 2007, Journal of aerosol medicine : the official journal of the International Society for Aerosols in Medicine.

[21]  D. Hess The mask for noninvasive ventilation: principles of design and effects on aerosol delivery. , 2007, Journal of aerosol medicine : the official journal of the International Society for Aerosols in Medicine.

[22]  Richard Beasley,et al.  An audiovisual reminder function improves adherence with inhaled corticosteroid therapy in asthma. , 2007, The Journal of allergy and clinical immunology.

[23]  L. Fabbri,et al.  Beclomethasone/formoterol versus budesonide/formoterol combination therapy in asthma , 2007, European Respiratory Journal.

[24]  P. Ind,et al.  Inhaled therapy in elderly COPD patients; time for re-evaluation? , 2007, Age and ageing.

[25]  W. Seeger,et al.  Iloprost-Containing Liposomes for Aerosol Application in Pulmonary Arterial Hypertension: Formulation Aspects and Stability , 2007, Pharmaceutical Research.

[26]  B. Rowe,et al.  Cochrane review: Holding chambers (spacers) versus nebulisers for beta‐agonist treatment of acute asthma , 2006 .

[27]  C. O’Callaghan,et al.  Enhanced delivery of nebulised salbutamol during non‐invasive ventilation , 2006, The Journal of pharmacy and pharmacology.

[28]  C. Crim,et al.  Efficacy and safety of fluticasone propionate hydrofluoroalkane inhalation aerosol in pre-school-age children with asthma: a randomized, double-blind, placebo-controlled study. , 2006, The Journal of pediatrics.

[29]  P. N. Souëf,et al.  Spacer inhalation technique and deposition of extrafine aerosol in asthmatic children , 2006, European Respiratory Journal.

[30]  L. Corbetta,et al.  The need to improve inhalation technique in Europe: a report from the Aerosol Drug Management Improvement Team. , 2006, Respiratory medicine.

[31]  K. Taylor,et al.  Formulations generated from ethanol‐based proliposomes for delivery via medical nebulizers , 2006, The Journal of pharmacy and pharmacology.

[32]  J. Oppenheimer Device Selection and Outcomes of Aerosol Therapy: Evidence-Based Guidelines , 2006 .

[33]  P. Barnes Corticosteroids: the drugs to beat. , 2006, European journal of pharmacology.

[34]  K. Sugibayashi,et al.  Kinetic Analysis on the Skin Disposition of Cytotoxicity as an Index of Skin Irritation Produced by Cetylpyridinium Chloride: Comparison of In Vitro Data using a Three-Dimensional Cultured Human Skin Model with In Vivo Results in Hairless Mice , 2006, Pharmaceutical Research.

[35]  M. Knowles,et al.  Mucus clearance and lung function in cystic fibrosis with hypertonic saline. , 2006, The New England journal of medicine.

[36]  H. Katinger,et al.  Nebulization of Liposomal rh-Cu/Zn–SOD with a Novel Vibrating Membrane Nebulizer , 2006, Journal of liposome research.

[37]  C. Leach,et al.  Influence of particle size and patient dosing technique on lung deposition of HFA-beclomethasone from a metered dose inhaler. , 2005, Journal of aerosol medicine : the official journal of the International Society for Aerosols in Medicine.

[38]  O. Usmani,et al.  Regional Lung Deposition and Bronchodilator Response as a Function of β2-Agonist Particle Size , 2005 .

[39]  D. Hess,et al.  Albuterol delivery during noninvasive ventilation. , 2005, Respiratory care.

[40]  J. Virchow,et al.  Inhaler choice in primary practice , 2005, European Respiratory Review.

[41]  R. Dhand Inhalation therapy with metered-dose inhalers and dry powder inhalers in mechanically ventilated patients. , 2005, Respiratory care.

[42]  K. Nikander,et al.  Variation in pediatric aerosol delivery: importance of facemask. , 2005, Journal of aerosol medicine : the official journal of the International Society for Aerosols in Medicine.

[43]  B. Laube,et al.  The expanding role of aerosols in systemic drug delivery, gene therapy, and vaccination. , 2005, Respiratory care.

[44]  C. Ramsay,et al.  Initial oxygen management in patients with an exacerbation of chronic obstructive pulmonary disease. , 2005, QJM : monthly journal of the Association of Physicians.

[45]  L. Hendeles,et al.  Automatic replacement of albuterol nebulizer therapy by metered-dose inhaler and valved holding chamber. , 2005, American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists.

[46]  P. Diot,et al.  In vitro study and semiempirical model for aerosol delivery control during mechanical ventilation , 2005, Intensive Care Medicine.

[47]  H. Cohen,et al.  Bacterial Contamination of Spacer Devices Used by Asthmatic Children , 2005, The Journal of asthma : official journal of the Association for the Care of Asthma.

[48]  K. Nikander,et al.  Adaptive Aerosol Delivery (AAD®) technology , 2004, Expert opinion on drug delivery.

[49]  R. Pauwels,et al.  Can guideline-defined asthma control be achieved? The Gaining Optimal Asthma ControL study. , 2004, American journal of respiratory and critical care medicine.

[50]  I. Amirav,et al.  Measurement of inspiratory flow in children with acute asthma , 2004, Pediatric pulmonology.

[51]  W. Hop,et al.  Determining factors of aerosol deposition for four pMDI-spacer combinations in an infant upper airway model. , 2004, Journal of aerosol medicine : the official journal of the International Society for Aerosols in Medicine.

[52]  P. Paré,et al.  The nature of small-airway obstruction in chronic obstructive pulmonary disease. , 2004, The New England journal of medicine.

[53]  G. Smaldone,et al.  Facemasks and facial deposition of aerosols , 2004, Pediatric pulmonology.

[54]  A. C. Moore,et al.  Meeting the needs of patients with COPD: patients' preference for the Diskus inhaler compared with the Handihaler , 2004, International journal of clinical practice.

[55]  J. C. Carranza Rosenzweig,et al.  Improved refill persistence with fluticasone propionate and salmeterol in a single inhaler compared with other controller therapies. , 2004, The Journal of allergy and clinical immunology.

[56]  M. Dolovich,et al.  Pulmonary drug delivery. Part I: physiological factors affecting therapeutic effectiveness of aerosolized medications. , 2003, British journal of clinical pharmacology.

[57]  G. Smaldone,et al.  Aerosol delivery and modern mechanical ventilation: in vitro/in vivo evaluation. , 2003, American journal of respiratory and critical care medicine.

[58]  G. Scheuch,et al.  Peripheral deposition of α1‐protease inhibitor using commercial inhalation devices , 2003, European Respiratory Journal.

[59]  P. N. Souëf,et al.  Distribution of technetium-99m-labelled QVARTM delivered using an AutohalerTM device in children , 2003, European Respiratory Journal.

[60]  Robert M. Kacmarek,et al.  In vitro evaluation of aerosol bronchodilator delivery during mechanical ventilation: pressure-control vs. volume control ventilation , 2003, Intensive Care Medicine.

[61]  C. Leach,et al.  Lung deposition of hydrofluoroalkane-134a beclomethasone is greater than that of chlorofluorocarbon fluticasone and chlorofluorocarbon beclomethasone : a cross-over study in healthy volunteers. , 2002, Chest.

[62]  J. Blum,et al.  Treatment of patients hospitalized for exacerbations of chronic obstructive pulmonary disease: comparison of an oral/metered-dose inhaler regimen and an intravenous/nebulizer regimen. , 2002, Respiratory care.

[63]  B. Dautzenberg,et al.  European Respiratory Society Guidelines on the use of nebulizers. , 2001, The European respiratory journal.

[64]  M. Silvasti,et al.  Efficacy of salbutamol via Easyhaler unaffected by low inspiratory flow. , 2000, Respiratory medicine.

[65]  W. Hop,et al.  Aerosol delivery from spacers in wheezy infants: a daily life study. , 2000, The European respiratory journal.

[66]  G. Waterer,et al.  Reducing electrostatic charge on spacer devices and bronchodilator response. , 2000, British journal of clinical pharmacology.

[67]  A. Bidani,et al.  Bronchodilator therapy with metered-dose inhaler and spacer versus nebulizer in mechanically ventilated patients: comparison of magnitude and duration of response. , 2000, Respiratory care.

[68]  C. Cole,et al.  Special problems in aerosol delivery: neonatal and pediatric considerations. , 2000, Respiratory care.

[69]  T. D. Robinson,et al.  The role of hypoventilation and ventilation-perfusion redistribution in oxygen-induced hypercapnia during acute exacerbations of chronic obstructive pulmonary disease. , 2000, American journal of respiratory and critical care medicine.

[70]  W. Busse,et al.  Efficacy response of inhaled beclomethasone dipropionate in asthma is proportional to dose and is improved by formulation with a new propellant. , 1999, The Journal of allergy and clinical immunology.

[71]  D. Georgopoulos,et al.  Bronchodilator delivery by metered-dose inhaler in mechanically ventilated COPD patients: influence of tidal volume , 1999, Intensive Care Medicine.

[72]  H. Donson,et al.  Home-made spacers for bronchodilator therapy in children with acute asthma: a randomised trial , 1999, The Lancet.

[73]  D. J. Velasquez,et al.  A new method to evaluate plume characteristics of hydrofluoroalkane and chlorofluorocarbon metered dose inhalers. , 1999, International journal of pharmaceutics.

[74]  H. Bisgaard,et al.  The effect of inhaled fluticasone propionate in the treatment of young asthmatic children: a dose comparison study. , 1999, American journal of respiratory and critical care medicine.

[75]  M. Newhouse,et al.  Clickhaler (a novel dry powder inhaler) provides similar bronchodilation to pressurized metered-dose inhaler, even at low flow rates. , 1999, Chest.

[76]  J. Wildhaber,et al.  Washing plastic spacers in household detergent reduces electrostatic charge and greatly improves delivery. , 1999, The European respiratory journal.

[77]  C. Leach,et al.  Improved airway targeting with the CFC-free HFA-beclomethasone metered-dose inhaler compared with CFC-beclomethasone. , 1998, The European respiratory journal.

[78]  C. Hörmann,et al.  Cardiopulmonary effects of aerosolized prostaglandin E1 and nitric oxide inhalation in patients with acute respiratory distress syndrome. , 1998, American journal of respiratory and critical care medicine.

[79]  S. Newman,et al.  Lung deposition of fenoterol and flunisolide delivered using a novel device for inhaled medicines: comparison of RESPIMAT with conventional metered-dose inhalers with and without spacer devices. , 1998, Chest.

[80]  H. Bisgaard,et al.  Clinical effect of Diskus dry-powder inhaler at low and high inspiratory flow-rates in asthmatic children. , 1998, The European respiratory journal.

[81]  M. Everard,et al.  Flow early in the inspiratory manoeuvre affects the aerosol particle size distribution from a Turbuhaler. , 1997, Respiratory medicine.

[82]  H. Bisgaard,et al.  Flow-dependent effect of formoterol dry-powder inhaled from the Aerolizer. , 1997, The European respiratory journal.

[83]  R. Pauwels,et al.  Airway deposition and airway effects of antiasthma drugs delivered from metered-dose inhalers. , 1997, The European respiratory journal.

[84]  M. Boussinesq,et al.  Serious reactions after mass treatment of onchocerciasis with ivermectin in an area endemic for Loa loa infection , 1997, The Lancet.

[85]  A. Kendrick,et al.  Selecting and using nebuliser equipment , 1997, Thorax.

[86]  S. Newman,et al.  Lung and oropharyngeal depositions of fenoterol hydrobromide delivered from the prototype III hand-held multidose Respimat nebuliser , 1997 .

[87]  R. Pauwels,et al.  GLOBAL STRATEGY FOR ASTHMA MANAGEMENT AND PREVENTION , 1996 .

[88]  I. Adcock,et al.  Glucocorticoid receptor localization in normal and asthmatic lung. , 1996, American journal of respiratory and critical care medicine.

[89]  S. Newman,et al.  Efficient delivery to the lungs of flunisolide aerosol from a new portable hand-held multidose nebulizer. , 1996, Journal of pharmaceutical sciences.

[90]  M. Tobin,et al.  Dose-response to bronchodilator delivered by metered-dose inhaler in ventilator-supported patients. , 1996, American journal of respiratory and critical care medicine.

[91]  M. Tobin,et al.  Aerosol delivery from a metered-dose inhaler during mechanical ventilation. An in vitro model. , 1996, American journal of respiratory and critical care medicine.

[92]  P. Barry,et al.  Inhalational drug delivery from seven different spacer devices. , 1996, Thorax.

[93]  W. Seeger,et al.  Direct comparison of inhaled nitric oxide and aerosolized prostacyclin in acute respiratory distress syndrome. , 1996, American journal of respiratory and critical care medicine.

[94]  B. Laube In vivo measurements of aerosol dose and distribution: clinical relevance. , 1996, Journal of aerosol medicine : the official journal of the International Society for Aerosols in Medicine.

[95]  P. Barry,et al.  The effect of delay, multiple actuations and spacer static charge on the in vitro delivery of budesonide from the Nebuhaler. , 1995, British journal of clinical pharmacology.

[96]  E. C. Smith,et al.  Comparison of twenty three nebulizer/compressor combinations for domiciliary use. , 1995, European Respiratory Journal.

[97]  B. Meakin,et al.  Simulated ‘in-use’ and ‘mis-use’ aspects of the delivery of terbutaline sulphate from Bricanyl TurbohalerTM dry powder inhalers , 1995 .

[98]  Jesse B. Hall,et al.  The assessment and management of adults with status asthmaticus. , 1995, American journal of respiratory and critical care medicine.

[99]  G. Crompton,et al.  Frequency of voice problems and cough in patients using pressurized aerosol inhaled steroid preparations. , 1995, The European respiratory journal.

[100]  C. Manthous,et al.  Metered-dose inhaler versus nebulized albuterol in mechanically ventilated patients. , 1995, The American review of respiratory disease.

[101]  P. Sly,et al.  The influence of age on aerosol deposition in children with cystic fibrosis. , 1994, The European respiratory journal.

[102]  K P Jones,et al.  Guidelines on the management of asthma. , 1993, Thorax.

[103]  R. Perry,et al.  Nebulizer function during mechanical ventilation. , 1992, The American review of respiratory disease.

[104]  S. Clarke,et al.  Improvement of drug delivery with a breath actuated pressurised aerosol for patients with poor inhaler technique. , 1991, Thorax.

[105]  G. Crompton,et al.  The use of a new breath-actuated inhaler by patients with severe airflow obstruction. , 1991, The European respiratory journal.

[106]  P. Barnes,et al.  Autoradiographic visualization of muscarinic receptor subtypes in human and guinea pig lung. , 1990, The American review of respiratory disease.

[107]  S. Pedersen,et al.  Influence of inspiratory flow rate upon the effect of a Turbuhaler. , 1990, Archives of disease in childhood.

[108]  P. Byron Respiratory Drug Delivery , 1989 .

[109]  C. McDonald,et al.  Comparison of outpatient nebulized vs metered dose inhaler terbutaline in chronic airflow obstruction. , 1989, Chest.

[110]  A. Gelb,et al.  Equivalence of continuous flow nebulizer and metered-dose inhaler with reservoir bag for treatment of acute airflow obstruction. , 1988, Chest.

[111]  G. Smaldone,et al.  Quantitative deposition of aerosolized gentamicin in cystic fibrosis. , 1987, The American review of respiratory disease.

[112]  Z. Mohsenifar,et al.  Cost-benefit comparison of aerosol bronchodilator delivery methods in hospitalized patients. , 1987, Chest.

[113]  S. Pedersen,et al.  How to use a rotahaler. , 1986, Archives of disease in childhood.

[114]  P. Barnes,et al.  Autoradiographic visualization of beta-adrenoceptor subtypes in human lung. , 1985, The American review of respiratory disease.

[115]  M. H. Williams,et al.  The adequacy of inhalation of aerosol from canister nebulizers. , 1980, The American journal of medicine.

[116]  M. Newhouse,et al.  Pulmonary aerosol deposition in chronic bronchitis: intermittent positive pressure breathing versus quiet breathing. , 1977, The American review of respiratory disease.

[117]  M. Newhouse,et al.  Aerosol penetrance: a sensitive index of peripheral airways obstruction. , 1976, Journal of applied physiology.

[118]  H. Chrystyn Effects of device design on patient compliance : Comparing the same drug in different devices. , 2009 .

[119]  F. Lavorini,et al.  Targeting drugs to the airways: The role of spacer devices. , 2009, Expert opinion on drug delivery.

[120]  J. Bousquet,et al.  Systemic Exposure and Implications for Lung Deposition with an Extra-Fine Hydrofluoroalkane Beclometasone Dipropionate/Formoterol Fixed Combination , 2009, Clinical pharmacokinetics.

[121]  T. Klassen,et al.  Nebulized hypertonic saline solution for acute bronchiolitis in infants. , 2008, The Cochrane database of systematic reviews.

[122]  G. Rodrigo Treatment of Acute Asthma , 2007 .

[123]  L. Osman,et al.  True device compliance: the need to consider both competence and contrivance. , 2005, Respiratory medicine.

[124]  J. L. Rau,et al.  Device selection and outcomes of aerosol therapy: Evidence-based guidelines: American College of Chest Physicians/American College of Asthma, Allergy, and Immunology. , 2005, Chest.

[125]  P. Haidl The Novolizer®: A Multidose Dry Powder Inhaler , 2005 .

[126]  A. Rossi,et al.  Dose-response effects and time course of effects of inhaled fenoterol on respiratory mechanics and arterial oxygen tension in mechanically ventilated patients with chronic airflow obstruction , 2005, Intensive Care Medicine.

[127]  T. Arakawa,et al.  Some Factors Associated with the Ultrasonic Nebulization of Proteins , 2004, Pharmaceutical Research.

[128]  K. Clancy British guidelines on the management of asthma. , 2004, Thorax.

[129]  N Moore,et al.  Assessment of handling of inhaler devices in real life: an observational study in 3811 patients in primary care. , 2003, Journal of aerosol medicine : the official journal of the International Society for Aerosols in Medicine.

[130]  G. Scheuch,et al.  Mass output and particle size distribution of glucocorticosteroids emitted from different inhalation devices depending on various inspiratory parameters. , 2002, Journal of aerosol medicine : the official journal of the International Society for Aerosols in Medicine.

[131]  M. Tobin,et al.  Improvement in aerosol delivery with helium-oxygen mixtures during mechanical ventilation. , 2001, American journal of respiratory and critical care medicine.

[132]  G. Pitcairn,et al.  Deposition and pharmacokinetics of flunisolide delivered from pressurized inhalers containing non-CFC and CFC propellants. , 2001, Journal of aerosol medicine : the official journal of the International Society for Aerosols in Medicine.

[133]  P. Barry,et al.  Comparison of the effectiveness of inhaler devices in asthma and chronic obstructive airways disease: a systematic review of the literature. , 2001, Health technology assessment.

[134]  T. Witek,et al.  Effective delivery of particles with the HandiHaler dry powder inhalation system over a range of chronic obstructive pulmonary disease severity. , 2001, Journal of aerosol medicine : the official journal of the International Society for Aerosols in Medicine.

[135]  R. Dhand,et al.  Selecting an accessory device with a metered-dose inhaler: variable influence of accessory devices on fine particle dose, throat deposition, and drug delivery with asynchronous actuation from a metered-dose inhaler. , 2001, Journal of aerosol medicine : the official journal of the International Society for Aerosols in Medicine.

[136]  E. Bendstrup,et al.  Jet and ultrasonic nebulization of single chain urokinase plasminogen activator (scu-PA). , 2000, Journal of aerosol medicine : the official journal of the International Society for Aerosols in Medicine.

[137]  B. Zierenberg Optimizing the in vitro performance of Respimat. , 1999, Journal of aerosol medicine : the official journal of the International Society for Aerosols in Medicine.

[138]  P. Duroux,et al.  [Modes of administration of beta agonists in asthma]. , 1996, Revue de Pneumologie Clinique.

[139]  G. Rudolf,et al.  A Mathematical Model of Mass Deposition in Man , 1994 .

[140]  J. Waldrep,et al.  Operating characteristics of 18 different continuous-flow jet nebulizers with beclomethasone dipropionate liposome aerosol. , 1994, Chest.

[141]  A. Hollingworth,et al.  The relationship between powder inhaler resistance and peak inspiratory conditions in healthy volunteers--implications for in vitro testing. , 1993, Journal of aerosol medicine : the official journal of the International Society for Aerosols in Medicine.

[142]  M. Lara,et al.  Guidelines For The Diagnosis And Management Of Asthma , 1992, The Journal of the American Board of Family Medicine.

[143]  D. Pavia,et al.  Effects of various inhalation modes on the deposition of radioactive pressurized aerosols. , 1982, European journal of respiratory diseases. Supplement.

[144]  G K Crompton,et al.  Problems patients have using pressurized aerosol inhalers. , 1982, European journal of respiratory diseases. Supplement.