Ibuprofen, paracetamol, and steam for patients with respiratory tract infections in primary care: pragmatic randomised factorial trial

Dear authors,

First I’d like to express my compliments for your practical research on this frequent and recurring problem. I have some questions about the validity of the results of steam inhalation in young children. Children aged three years and older were included. I doubt whether three-year old children will be able to understand the purpose of the steam inhalation and therefore I also doubt whether their inhalation technique will be adequate. In other forms of inhalation therapy, for instance asthma therapy, it is known that the inhalation technique of young children is very poor. (1)

Inhalation of steam will reach the upper airway more easily than the lower airway. Because children with lower airway infections were included, it is possible that they did not inhale deep enough and the steam could not reach the lower airway.
I wonder if the effect of adequate steam inhalation in older patients with upper airway infections would have showed more relieve of symptoms than in this unselected population.

(1). Kamps AW, van Ewijk B, Roorda RJ, Brand PL. Poor inhalation technique, even after inhalation instructions, in children with asthma. Pediatr Pulmonol. 2000 Jan;29(1):39-42.