Use of QVAR with a spacer device in children less than 5 years of age is not recommended. In vitro dose characterization studies were performed with QVAR 40 mcg/actuation with the OptiChamber and AeroChamber Plus ® spacer utilizing inspiratory flows representative of children under 5 years old. These studies indicated that the amount of medication delivered through the spacing device decreased rapidly with increasing wait times of 5 to 10 seconds as shown in Table 2. If QVAR is used with a spacer device, it is important to inhale immediately.
We identified seven randomised trials (5997 participants) of good quality with a duration of six months to three years. All of the trials compared ICS/LABA combination inhalers with LABA and ICS as individual components. Four of these trials included fluticasone and salmeterol monocomponents and the remaining three included budesonide and formoterol monocomponents. There was no statistically significant difference in our primary outcome , the number of patients experiencing exacerbations ( odds ratio ( OR ) ; 95% CI to ), or the rate of exacerbations per patient year (rate ratio ( RR ) ; 95% CI to ) between inhaled corticosteroids and long-acting beta 2 -agonists. The incidence of pneumonia, our co-primary outcome , was significantly higher among patients on inhaled corticosteroids than on long-acting beta 2 -agonists whether classified as an adverse event ( OR ; 95% CI to ) or serious adverse event (Peto OR ; 95% CI to ). Results of the secondary outcomes analysis were as follows. Mortality was higher in patients on inhaled corticosteroids compared to patients on long-acting beta 2 -agonists (Peto OR ; 95% CI to ), although the difference was not statistically significant . Patients treated with beta 2 -agonists showed greater improvements in pre-bronchodilator FEV 1 compared to those treated with inhaled corticosteroids ( mean difference ( MD ) mL; 95% CI to ), whilst greater improvements in health-related quality of life were observed in patients receiving inhaled corticosteroids compared to those receiving long-acting beta 2 -agonists (St George's Respiratory Questionnaire (SGRQ) MD -; 95% CI - to -). In both cases the differences were statistically significant but rather small in magnitude. There were no statistically significant differences between ICS and LABA in the number of hospitalisations due to exacerbations, number of mild exacerbations, peak expiratory flow, dyspnoea , symptoms scores, use of rescue medication, adverse events, all cause hospitalisations, or withdrawals from studies.