Higher-delivery chamber improves acute wheezing outcomes
In young children with acute wheezing, a higher-delivery inhaler chamber improved breathing scores and reduced hospitalizations versus a lower-delivery chamber.
*Multicenter randomized clinical trial; Level 1b (OCEBM).

Citation

Csonka P, Ruuska-Loewald T, Hämynen I, et al. Valved Holding Chambers in Young Children With Acute Wheezing: A Randomized Clinical Trial. JAMA Pediatrics. 2026;180(5):567-574. doi:10.1001/jamapediatrics.2025.6479. Trial registration: NCT03900494.

Background

Commercial inhaler “holding chambers” can deliver different amounts of medicine in lab testing, but it has been unclear whether that affects real outcomes in toddlers with acute wheezing in emergency care.

Patients

Children aged 6 to 48 months with moderate to severe wheezing distress in emergency settings (breathing distress score ≥6). Key exclusions: oxygen saturation <85% on arrival, suspected pneumonia/croup/foreign body, immediate need for inpatient care, major chronic illness or immune compromise.

Intervention

Salbutamol via a higher-delivery holding chamber with its matching face mask (0.6 mg per cycle, up to 3–4 cycles).

Control

Same salbutamol dosing via a lower-delivery holding chamber with its matching face mask.

Outcome

Primary: post-treatment Respiratory Distress Assessment Instrument score (0–17) and change from baseline. Secondary: hospitalization, need for a 4th dose, breathing rate, oxygen saturation.

Follow-up Period

During the emergency visit (about 60–90 minutes).

Results

Outcome Higher-delivery vs lower-delivery chamber Between-group effect (95% CI) NNT
Breathing distress score after treatment (primary) 2.7 vs 6.8 (mean) Mean difference −4.1 (−5.4 to −2.7) —
Change in breathing distress score (primary) −8.6 vs −3.2 (mean) Mean difference −5.4 (−6.9 to −3.9) —
Hospitalization 20% vs 50% Absolute risk reduction 30% (9% to 49%) 3.3
Needed a 4th salbutamol dose 58% vs 80% Relative risk 0.72 (0.51 to 0.97) 4.4
Oxygen saturation after treatment 97% vs 94% (mean) Mean difference +2.5% (+1.4% to +3.7%) —
Results were analyzed by intention-to-treat (all randomized children included).

Limitations

Nurses and families could not be blinded to the device; only clinicians scoring outcomes were blinded. Small sample size (80 children) and Finland-only sites may limit generalizability. Findings apply to these two specific devices and masks, not all products.

Funding

Finnish academic foundations and Finnish state hospital research funding.

Clinical Application

For toddlers with moderate-to-severe acute wheezing, choose a well-performing holding chamber; device choice can reduce distress and may prevent hospitalization.