NICE Technology Appraisal Guidance - No. 38 Inhaler devices for
routine treatment of chronic asthma in older children (aged 5-15
Appraisal Guidance - No. 38 Inhaler devices for routine treatment
of chronic asthma in older children (aged 5-15 years)
The Health Technology Board for Scotland (HTBS) is delivering
this National Institute for Clinical Excellence (NICE) Guidance to
health professionals in NHSScotland with the following
authoritative Comment on its use in Scotland. This HTBS
Comment must be read in conjunction with the NICE Guidance.
HTBS advises that the NICE Technology Appraisal Guidance - No.
38 Inhaler devices for routine treatment of chronic asthma in older
children (aged 5-15 years) is as valid for Scotland as for England
and Wales. It is linked to this page for your information.
The NICE recommendations are shown below.
- 1.1 It is recommended that in addition to therapeutic need
(including chosen drug and dose), the following factors be taken
into account when choosing inhaler devices for individual children
with chronic asthma:
• the ability of the child to develop and maintain an
technique with the specific device
• the suitability of a device for the child and carer’s
considering factors such as portability and convenience
• the child’s preference for and willingness to use a particular
- 1.2 The general recommendations in 1.1 should be taken into
account when considering the following specific guidance:
1.2.1 A press-and-breathe pressurised metered dose inhaler (pMDI)
and suitable spacer device is recommended as the first-line choice
for the delivery of inhaled corticosteroids as part of regular
planned daily therapy, with the aim of maximizing benefits of
preventive therapy in attaining good asthma control, and minimising
potential systemic absorption. Where clinicians believe that an
individual child’s adherence to the press-and-breathe pMDI and
spacer combination is likely to be so poor as to undermine
effective asthma control, other alternative devices (taking account
of the factors outlined in 1.1
and evidence of equivalence of clinical effectiveness) should be
considered, bearing in mind the need to minimise the risks of
systemic absorption of corticosteroids.
1.2.2 In the case of other inhaled drugs, primarily
bronchodilators, it is recommended that a wider range of devices be
considered to take account of their more frequent spontaneous use,
the greater need for portability, and the clear feedback that
symptom response provides to the device user. In such circumstances
the factors outlined in 1.1 are likely to be of greater importance
in choosing a device.
- 1.3 Where more than one device satisfies the considerations
outlined above in a particular child, it is recommended that the
device with the lowest overall cost (taking into account daily
required dose and product price per dose) should be chosen.
- 1.4 On selection of an inhaler device, it is important that
consideration is given to other aspects of asthma care that
influence the effective delivery of inhaled therapy,
• individual practical training in the use of the specific
• monitoring of effective inhaler technique and adherence to
• regular (i.e. no less than annual) review of inhaler needs, which
change over time with increasing age.
HTBS anticipates that implementing this NICE Guidance in
Scotland will have the following implications for NHSScotland:
- It is anticipated that the Scottish Intercollegiate Guidelines
Network (SIGN), jointly with the British Thoracic Society (BTS),
will publish revised guidelines on asthma in September 2002
- Attention is drawn to the NICE Guidance No. 10 Guidance on the
use of inhaler systems (devices) in children under the age of 5
years with chronic asthma published in August 2000 (http://www.nice.org.uk/).
- Health professionals and NHS organisations with responsibility
for treating children aged 5-15 years with chronic asthma should
review their current practice in line with this guidance on inhaler
- Health professionals involved in the prescribing, supply, and
administration of inhaler devices to children should be
appropriately trained, be able to explain about the full range of
inhalers available and provide effective training in the proper use
- To enable health professionals to audit their own compliance
with this guidance it is recommended that local protocols are
adapted or, if none exist, developed and implemented locally.
Appendix D of the NICE Guidance outlines the technical details of
the use of specific criteria for audit purposes. In addition,
NHS Boards, Trusts, LHCCs and practice teams may wish to monitor
their prescribing of inhaler types.
- Scotland should participate in the recommended further research
on inhaler devices (NICE Guidance Section 6).
- Data from the 1998 Scottish Health Survey (Shaw A, McMunn A and
Field J (eds). 2000. The Scottish Health Survey 1998: Volume
1: Findings. Edinburgh: The Stationery Office) shows a prevalence
of diagnosed asthma among children aged 2-15 years of 16% for girls
and 19% for boys. The prevalences for the 2-6, 7-10 and 11-15
age groups are similar and therefore the 2-15 age group prevalence
is a reasonable estimate of the prevalence in children aged
- The estimated Scottish population of children aged 5-15 is
316,154 girls and 331,683 boys. This gives figures in
Scotland for those with diagnosed asthma of 50,585 girls and 63,020
- It is difficult to predict the impact of this advice (except
for spacer devices) because the budget impact is very sensitive to
device prescribing patterns, as acquisition costs of inhalers
delivering the same class of drug at the same dose vary
substantially (NICE Guidance Section 5.1). Consequently, the
estimated current inhaler costs, and the estimated costs of
additional spacer devices for Scotland, are shown below.
- The NICE Guidance assumed that in England and Wales 60% of
those diagnosed with asthma use press-and-breathe pMDIs, 17% use
breath-actuated pMDIs, and 23% use DPIs. Assuming there is a
similar treatment pattern in Scotland, that all children with
diagnosed asthma receive bronchodilators, and that 80% receive
corticosteroids, the estimated current annual acquisition costs in
Scotland for inhaler devices for children aged 5-15 years is £3.6m
(NICE Guidance Sections 5.2 and 5.3).
- The cost of introducing a press-and-breathe pMDI and suitable
spacer as the first line choice for delivering inhaled
corticosteroids would increase the rate of prescribing of such
spacer devices from 20% to 100% and the total acquisition costs of
spacers would increase by £0.1m for NHSScotland (NICE Guidance
- The wider resource implications of implementing this advice in
relation to training and audit, noting in particular Sections 1.4
and 7.3 of the NICE Guidance, are not costed in this Comment.
NHSScotland should take account of this Comment from HTBS and
recommended drugs or treatments are made available to meet clinical
This HTBS Comment is the result of a consideration of possible
contextual differences in Scotland, according to the following
- Principles and values of NHSScotland
- Epidemiology (frequency and distribution)
- Structure and provision of services in Scotland
- Other implications for the Scottish Health Service.
No important differences were identified for this NICE
Technology Appraisal Guidance. The process used is available on
request or from this site.
An Understanding HTBS Advice is also being distributed on this
topic and is available from this website.
HTBS would like to thank NICE for its cooperation in delivering
this Comment. HTBS is also grateful to the experts in Scotland who
provided input to this Comment.
Published Date: 17 May 2001