Asthma Management Handbook

Considering if regular preventer treatment is indicated in children 0–5 years

Recommendations

Discuss the goals of asthma treatment with the child’s parents. Explain that the overall aims of treatment are to make sure asthma does not interfere with the child’s quality of life and to minimise the side effects of treatment by using the lowest level of medication required to maintain good asthma control.

Figure. Stepped approach to adjusting asthma medication in children Opens in a new window Please view and print this figure separately: https://www.asthmahandbook.org.au/figure/show/18

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

Prescribe a reliever based on the child’s age and clinical significance of their symptoms. Educate parents how and when to give reliever, and advise them to carry reliever at all times to use when needed to manage symptoms.

Table. Non-emergency use of bronchodilators (relievers) in children aged 0–5 years

Age Notes Salbutamol dose and delivery

0–6 months

Consider discussing with a paediatric respiratory physician or paediatrician before prescribing an inhaled short-acting beta2 agonist (salbutamol).

2–4 puffs (100 mcg per puff) as needed via pressurised metered-dose inhaler, spacer and face mask

6–12 months

Consider managing wheezing episodes with an inhaled short-acting beta2 agonist bronchodilator (salbutamol) only if wheezing is associated with increased work of breathing (i.e. intercostal retraction)

Use inhaled salbutamol with caution and discontinue if wheezing does not resolve promptly after use. 

2–4 puffs (100 mcg per puff) as needed via pressurised metered-dose inhaler, spacer and face mask

1–5 years

Manage wheezing episodes with inhaled short-acting beta2 agonist (salbutamol) as needed if associated with increased work of breathing (i.e. intercostal retraction).

Usual dose: 2–4 puffs (100 mcg per puff) as needed via pressurised metered-dose inhaler, spacer and face mask (infants) or spacer (if old enough to cooperate)

Note: This table lists usual salbutamol doses to be administered by carers in the community to manage symptoms as needed. Doses are higher during acute episodes, including emergencies.

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How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

Consider regular preventer treatment according to age and pattern of symptoms.

Note: This assessment should be based on overall pattern of symptoms between flare-ups, not on symptoms seen during short-term (e.g. during a flare-up).

Table. Initial preventer treatment for children aged 0–5 years

Age

Pattern of symptoms

Management options and notes *

0–12 months

Intermittent asthma

or

Viral-induced wheeze

Regular preventer treatment is not recommended

Multiple-trigger wheeze

Refer for specialist assessment or obtain specialist advice before prescribing

1–2 years

Intermittent asthma

or

Viral-induced wheeze

Regular preventer treatment is not recommended

Persistent asthma

or

Multiple-trigger wheeze

Consider a treatment trial with sodium cromoglycate 10 mg three times daily and review response in 2–4 weeks

Consider a treatment trial of low-dose inhaled corticosteroids only if wheezing symptoms are disrupting child’s sleeping or play; review response in 4 weeks

2–5 years

Infrequent intermittent asthma

or

Viral-induced wheeze

Regular preventer treatment is not recommended

Frequent intermittent asthma

or

Mild persistent asthma

or

Episodic (viral) wheeze with frequent symptoms

or

Multiple-trigger wheeze

Consider regular treatment with montelukast 4 mg once daily and review response in 2–4 weeks

If symptoms do not respond, consider regular treatment with a low dose of an inhaled corticosteroid and review response in 4 weeks

Moderate–severe persistent asthma

or

Moderate–severe multiple-trigger wheeze

Consider regular treatment with a low dose of an inhaled corticosteroid and review response in 4 weeks

  • Advise parents about potential adverse psychiatric effects of montelukast

* In addition to use of rapid-onset inhaled beta2 agonist when child experiences difficulty breathing

† Starting dose sodium cromoglycate 10 mg (two inhalations of 5 mg/actuation inhaler) three times daily. If good response, reduce to 10 mg twice daily when stable. Cromone inhaler device mouthpieces require daily washing to avoid blocking. 

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Table. Definitions of asthma patterns in children aged 0–5 years not taking regular preventer

Category

Pattern and intensity of symptoms (when not taking regular treatment)

Infrequent intermittent asthma

Symptom-free for at least 6 weeks at a time (flare-ups up to once every 6 weeks on average but no symptoms between flare-ups)

Frequent intermittent asthma

Flare-ups more than once every 6 weeks on average but no symptoms between flare-ups

Persistent asthma

Mild

At least one of:

  • Daytime symptoms more than once per week but not every day
  • Night-time symptoms more than twice per month but not every week

Moderate

Any of:

  • Daytime symptoms daily
  • Night-time symptoms more than once per week
  • Symptoms sometimes restrict activity or sleep

Severe

Any of:

  • Daytime symptoms continual
  • Night-time symptoms frequent
  • Flare-ups frequent
  • Symptoms frequently restrict activity or sleep

† Symptoms between flare-ups. A flare-up is defined as a period of worsening asthma symptoms, from mild (e.g. symptoms that are just outside the normal range of variation for the child, documented when well) to severe (e.g. events that require urgent action by parents and health professionals to prevent a serious outcome such as hospitalisation or death from asthma).

Note: Use this table when the diagnosis of asthma can be made with reasonable confidence (e.g. a child with wheezing accompanied by persistent cough or breathing difficulty, no signs or symptoms that suggest a potentially serious alternative diagnosis, and the presence of other factors that increase the probability of asthma such as family history of allergies or asthma).

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How this recommendation was developed

Adapted from existing guidance

Based on reliable clinical practice guideline(s) or position statement(s):

  • van Asperen et al. 2010 1
  • Brand et al. 2008 2

For children aged 2 years and older with frequent intermittent asthma or mild persistent asthma/wheezing, consider montelukast as first-choice preventer.

  • Advise parents about potential adverse psychiatric effects of montelukast
How this recommendation was developed

Adapted from existing guidance

Based on reliable clinical practice guideline(s) or position statement(s):

  • van Asperen et al. 2010 1
  • Brand et al. 2008 2

For children aged 2 years and older with moderate-to-severe persistent asthma, consider an inhaled corticosteroid (low dose) as first-choice preventer.

Table. Definitions of ICS dose levels in children

Inhaled corticosteroid

Daily dose (mcg)

Low

High

Beclometasone dipropionate

100–200

>200 (up to 400)

Budesonide

200–400

>400 (up to 800)

Ciclesonide

80–160

>160 (up to 320)

Fluticasone propionate

100–200

>200 (up to 500)

† Dose equivalents for Qvar (TGA-registered CFC-free formulation of beclometasone dipropionate)

‡ Ciclesonide is registered by the TGA for use in children aged 6 and over

Source

van Asperen PP, Mellis CM, Sly PD, Robertson C. The role of corticosteroids in the management of childhood asthma. The Thoracic Society of Australia and New Zealand, 2010. Available from: 
http://www.thoracic.org.au/clinical-documents/area?command=record&id=14

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How this recommendation was developed

Adapted from existing guidance

Based on reliable clinical practice guideline(s) or position statement(s):

  • van Asperen et al. 20101

Sodium cromoglycate can be considered for children less than 2 years old. Sodium cromoglycate or nedocromil can be considered for children older than 2 years who are unable to tolerate montelukast. 

How this recommendation was developed

Adapted from existing guidance

Based on reliable clinical practice guideline(s) or position statement(s):

  • van Asperen et al. 20101

Inhaled corticosteroid/long-acting beta2 agonist combinations are not recommended for children aged 0–5 years.

How this recommendation was developed

Adapted from existing guidance

Based on reliable clinical practice guideline(s) or position statement(s):

  • van Asperen et al. 2010 1

More information

Montelukast for children

Montelukast is registered by the TGA for use in children aged 2 years and older.3

Based on data from placebo-controlled trials, it has not been possible to define clinical indicators that predict which children will benefit most from montelukast therapy, compared with other treatment options.45

Comparative studies suggest that the main role for montelukast is as an alternative to low-dose inhaled corticosteroid in children with frequent intermittent asthma or mild persistent asthma.4

Children 0–5 years

In preschool children with multiple-trigger wheeze, montelukast protects against airway hyperresponsiveness when taken with or without inhaled corticosteroids.2 Inhaled corticosteroids are more effective than montelukast in children with multiple-trigger wheeze aged 2–8 years,6 but this comparison has not been made in preschool children as a separate group.2

In children aged 2–5 years with episodic (viral) wheeze, regular montelukast treatment reduces the risk of wheezing episodes.7 However, montelukast may not reduce symptoms in children aged 6–24 months with recurrent wheeze.8 

Note: Montelukast is not TGA-registered for use in children younger than 2 years.

A short course of montelukast, introduced at the first signs of an asthma episode or upper respiratory tract infection, can achieve a small reduction in symptoms, school absence and medical consultations in preschool and school-aged children with episodic wheeze.9 However, montelukast is not TGA-registered for intermittent use.

Children 6 years and over

In school-aged children with persistent asthma, inhaled corticosteroids are more effective than montelukast for a range of measures, including lung function.4

In school-aged children with persistent exercise-induced symptoms despite taking regular inhaled corticosteroids, montelukast is effective in controlling symptoms and is more effective than long-acting beta2 agonists.110

In children who are already taking regular inhaled corticosteroids and have a beta2 receptor genotype associated with increased susceptibility to flare-ups during regular long-acting beta2 agonist therapy,11 montelukast may be more effective than salmeterol in reducing symptoms, reliever use and days absent from school due to asthma, based on the findings of a small randomised controlled clinical trial.11

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Montelukast for children: warning parents about potential psychiatric adverse effects

Montelukast is generally very well tolerated.1 However, post-marketing surveillance reports suggested a slight increase in the rate of psychiatric disorders that was possibly associated with use of leukotriene receptor antagonists in children;12 this association may have been confounded by asthma severity and concomitant medication.1 Montelukast use has also been associated with suicidal ideation, but a recent nested case-control study concluded that children with asthma aged 5–18 years taking leukotriene receptor antagonists were not at increased risk of suicide attempts.13 Behavioural and psychiatric adverse effects were rare in clinical trials.14,15

A recent analysis of databases of adults and children taking montelukast suggests it is associated with nightmares, depression, and aggression.16 Allergic granulomatous angiitis has also been reported, but a causal relationship has not been established.16

The Thoracic Society of Australia and New Zealand advises that it is prudent to mention to parents the potential association of montelukast with behaviour-related adverse events when commencing treatment, and to cease therapy if such adverse events are suspected.1

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Cromones for children

0-5 years

Few clinical trials have assessed the use of inhaled sodium cromoglycate in preschool children and none have assessed nedocromil.2 Overall, sodium cromoglycate has not been shown to be effective in preschool children with multiple-trigger wheeze.2, 17

However, cromones are well tolerated and registered for use in infants. Therefore, a treatment trial can be considered before considering other preventers, particularly for children less than 2 years old.

6 years and over

Cromones are rarely prescribed in school-aged children.

Inhaled sodium cromoglycate might be effective in school-aged children, but interpretations of available evidence are inconsistent.1 Sodium cromoglycate is less effective than inhaled corticosteroid in achieving asthma control and improving lung function in children with persistent asthma.18

Nedocromil sodium appears to be have some benefit in children with persistent asthma, but its relative effectiveness compared with inhaled corticosteroids is not clear.19 Long-term (4–6 years) treatment with budesonide achieved better asthma control than long-term nedocromil in children with mild-to-moderate asthma aged 5–12 in a randomised placebo-controlled clinical trial.20

Practical issues

Cromones (sodium cromoglycate and nedocromil) may not be practical for some patients, because they require three–four times daily dosing until control is gained, and inhaler devices for cromones tend to block easily.1

Nedocromil can cause an unusual or unpleasant taste21 and is not tolerated by some children.

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Inhaled corticosteroids for children: overview

The effectiveness of ICS in children appears to depend on several factors including the child’s age, which triggers are causing symptoms, wheezing phenotype, tobacco smoke exposure and genotype.22 Overall, inhaled corticosteroids seem to be more effective in older children and those with more severe disease.1

Early introduction of inhaled corticosteroid for children with recurrent wheeze does not prevent airway remodelling, improve long-term lung function or prevent the onset of persistent asthma, according to current evidence from long-term randomised controlled clinical trials in preschool children and school-aged children with intermittent or mild persistent asthma.1

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Inhaled corticosteroids for children: 0–5 years

In preschool children with episodic (viral) wheeze, limited available evidence suggests that regular treatment with inhaled corticosteroids does not reduce the risk of hospitalisation, flare-ups that require oral corticosteroid use, or reduce the frequency and duration of acute episodes.2223 Inhaled corticosteroid treatment does not reduce these children’s risk of developing persistent wheeze by age 6 years.2

Regular treatment with inhaled corticosteroids improves wheezing, asthma symptoms and lung function and reduces flare-ups in infants and preschoolers with persistent (at least 6 months) wheezing or asthma.124 

In preschool children with multiple-trigger wheeze, regular inhaled corticosteroids are moderately effective in controlling symptoms, but less effective than in older children.2 When multiple-trigger wheeze improves markedly during a short treatment trial (e.g. 3 months), it is not possible to tell whether improvement was due to the treatment or natural resolution of symptoms.2

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Inhaled corticosteroids for children: doses

In the majority of children, asthma control can be achieved with any of the following initial doses:1

  • budesonide 400 mcg/day
  • beclometasone (Qvar) 200 mcg/day
  • ciclesonide 160 mcg/day
  • fluticasone propionate 200 mcg/day.

If these doses do not achieve control of symptoms, possible explanations include alternative diagnoses, adherence, incorrect inhaler technique, psychosocial factors and exposure to tobacco smoke or other triggers such as allergens.1

Dose–response studies of inhaled corticosteroids show that the maximal efficacy is generally achieved at a dose equivalent to approximately 200 mcg/day fluticasone propionate,1 while the risk of adrenal suppression increases exponentially at doses above 500 mcg/day.1 Therefore (based on theoretical equivalents between different agents), upper limits of daily doses for children are:

  • budesonide 800 mcg/day
  • beclometasone dipropionate [Qvar] 400 mcg/day
  • ciclesonide 320 mcg/day
  • fluticasone propionate 500 mcg/day.

Higher doses are unlikely to be more effective, and are likely to cause systemic effects.1

Most studies of inhaled corticosteroids in children have used twice-daily dosing.1  Ciclesonide is effective when given once daily.1 The dose of inhaled corticosteroid delivered to the lungs will depend on many factors, including the delivery device, the age of the child, individual variation in inhaler technique, and adherence.1

Note: Do not use beclometasone dose recommendations from outdated or overseas guidelines based on older formulations containing CFC propellant – doses are different.

Table. Definitions of ICS dose levels in children

Inhaled corticosteroid

Daily dose (mcg)

Low

High

Beclometasone dipropionate

100–200

>200 (up to 400)

Budesonide

200–400

>400 (up to 800)

Ciclesonide

80–160

>160 (up to 320)

Fluticasone propionate

100–200

>200 (up to 500)

† Dose equivalents for Qvar (TGA-registered CFC-free formulation of beclometasone dipropionate)

‡ Ciclesonide is registered by the TGA for use in children aged 6 and over

Source

van Asperen PP, Mellis CM, Sly PD, Robertson C. The role of corticosteroids in the management of childhood asthma. The Thoracic Society of Australia and New Zealand, 2010. Available from: 
http://www.thoracic.org.au/clinical-documents/area?command=record&id=14

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Inhaled corticosteroids for children: adverse effects

Topical

Hoarseness and pharyngeal candidiasis are not commonly reported among preschool children when using a metered-dose inhaler with spacer,2 or among school-aged children.1

Inhaled corticosteroids, particular dry-powder formulas with pH <5.5, may dissolve tooth enamel in children.1

Topical effects can be reduced by use of spacer devices (which reduce oropharyngeal deposition), and by mouth-rinsing and spitting after use.1 Immediate quick mouth-rinsing removes more residual medicine in the mouth than delayed rinsing.25

Systemic

Systemic effects of inhaled corticosteroids in children depend on the dose, but clinically significant adverse effects are uncommon.1 The use of spacers and mouth rinsing will not reduce systemic effects, but may increase efficacy so that a lower dose is required.

Short-term suppression of linear growth has been demonstrated in children, but only minimal long-term effects on growth or bone density have been reported.1 Some children may experience delay in the normal pubertal growth spurt due to asthma itself.1 Treatment beginning before puberty is associated with a small (mean approximately 1 cm) reduction in adult height.26

A research study using biochemical testing in a research setting showed that hypothalamic–pituitary–adrenal axis suppression may occur in up to two-thirds of children treated with inhaled corticosteroids, and may occur at even low doses.27 However, clinically cases are rare.

Cases of symptomatic, clinically significant adrenal insufficiency in children due to inhaled corticosteroid treatment have been reported,2829 including cases in Australia.30 Most cases have involved children given more than 500 mcg per day fluticasone propionate.28

The risk of hypothalamic–pituitary–adrenal axis suppression is higher among children receiving concomitant intranasal steroids and those with lower body mass index.27 Risk is lower in obese children.27

There are no nationally accepted protocols for routine assessment of adrenal function because it has not yet been possible to identify precisely which children should be tested, to interpret test results reliably, to identify the appropriate interval for retesting, and because a clinical benefit has not been clearly demonstrated.

Table. Definitions of ICS dose levels in children

Inhaled corticosteroid

Daily dose (mcg)

Low

High

Beclometasone dipropionate

100–200

>200 (up to 400)

Budesonide

200–400

>400 (up to 800)

Ciclesonide

80–160

>160 (up to 320)

Fluticasone propionate

100–200

>200 (up to 500)

† Dose equivalents for Qvar (TGA-registered CFC-free formulation of beclometasone dipropionate)

‡ Ciclesonide is registered by the TGA for use in children aged 6 and over

Source

van Asperen PP, Mellis CM, Sly PD, Robertson C. The role of corticosteroids in the management of childhood asthma. The Thoracic Society of Australia and New Zealand, 2010. Available from: 
http://www.thoracic.org.au/clinical-documents/area?command=record&id=14

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Inhaled corticosteroid/long-acting beta-2 agonist combinations for children: 0–5 years

The combination of salmeterol plus fluticasone propionate in a single inhaler is registered for use in children 4 years and older.31 The use of long-acting beta2 agonists in combination with inhaled corticosteroids has not been studied in children under 4 years old.32 Australian1 and international33 guidelines recommend against the use of long-acting beta2 agonists in children aged 5 years or less.

In children aged 5 years or less with asthma that is not adequately controlled by low-dose inhaled corticosteroid alone, adding montelukast is preferable to adding a long-acting beta2 agonist or increasing the dose of inhaled corticosteroids when the safety profiles of these options are compared.34

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Approaches to assessment and monitoring of asthma control in children

Assessment of asthma control in children is based mainly on recent asthma symptom control (assessed by the frequency and severity of symptoms between flare-ups and the degree to which asthma symptoms affect daily activities such as interference with physical activity or missed school days), the frequency of flare-ups, and spirometry in children who are able to perform the test reliably.

Parents commonly underestimate the severity of their child's asthma and overestimate asthma control.35

Standardised questionnaires

Questionnaire-based instruments have been validated for assessing asthma control in children:

Measures of airway inflammation

Measures of airway inflammation (e.g. sputum test, exhaled nitric oxide) are not used in clinical practice to guide treatment decisions. Tailoring the dose of inhaled corticosteroids based on exhaled nitric oxide appears to achieve only a small benefit in children, and may lead to higher doses.41 

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Administration of inhaled medicines in children: 0–5 years

To use inhaler devices correctly, parents and children need training in inhaler technique and in the care and cleaning of inhalers and spacers.

Children need careful supervision when taking their inhaled medicines (e.g. at preschool), especially when using a reliever for acute asthma symptoms. 

During acute wheezing episodes, delivery of short-acting beta2 agonist to airways is more effective with a pressurised metered-dose inhaler plus spacer than with a nebuliser.2 In older children, salbutamol has also been associated with a greater increase in heart rate when delivered by nebuliser than when delivered by pressurised metered-dose inhaler plus spacer.42

Dry-powder inhalers are usually ineffective for preschool children because they cannot generate sufficient inspiratory air flow.2

Preschool children cannot use pressurised metered-dose inhalers properly unless a spacer is attached (with mask when necessary), because it is difficult for them to coordinate inspiratory effort with firing the device.2 Note that breath-actuated pressurised metered-dose inhalers cannot be used with a spacer.

Even when using pressurised metered dose inhalers and spacers, drug delivery is very variable in young children.43 The inhaler design may improve spacer technique,43 but will not necessarily improve clinical outcomes. The amount of medicine delivered by inhaler devices to the lower airways varies from day to day in preschool children.2 This variation might explain fluctuations in effectiveness, even if the child’s parents have been trained to use the device correctly.

When administering salbutamol to relieve asthma symptoms in a preschool child, the standard recommendation is to shake the inhaler, fire one puff at a time into the spacer and have the child take 4–6 breaths in and out of the spacer (tidal breathing).44 Fewer breaths may suffice; in children with asthma aged 2–7 years (not tested during an acute asthma episode), the number of tidal breaths needed to inhale salbutamol adequately from a spacer has been estimated at 2 breaths for small-volume spacers, 2 breaths for a spacer made from a 500-mL modified soft drink bottle, and 3 breaths for a large (Volumatic) spacer.45

When using a spacer with face mask (e.g. for an infant too young or uncooperative to be able to use a mouthpiece), effective delivery of medicine to the airways depends on a tight seal around the face. When masks are used for inhaled corticosteroids, there is a risk of exposure to eyes and skin if the seal over the mouth and nose is not adequate. Parents should be advised to wash the child's face after administering inhaled corticosteroids by mask.

Babies are unlikely to inhale enough medicine while crying.42 The use of a spacer and face mask for a crying infant may require patience and skill: the child can be comforted (e.g. held by a parent, in own pram, or sitting on the floor) while the mask is kept on, and the actuation carefully timed just before the next intake of breath. Most infants will tolerate the spacer and mask eventually. The child may be more likely to accept the spacer and mask if allowed to handle them first (and at other times), if the devices are personalised (e.g. with stickers), or if the mask has a scent associated with the mother (e.g. lip gloss). The use of a spacer with a coloured valve allows parents to see the valve move as the child breathes in and out.

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Correct use of inhaler devices

The majority of patients do not use inhaler devices correctly. Australian research studies have reported that only approximately 10% of patients use correct technique.4647

High rates of incorrect inhaler use among children with asthma and adults with asthma or COPD have been reported,48, 49, 50, 51, 52 even among regular users.53 Regardless of the type of inhaler device prescribed, patients are unlikely to use inhalers correctly unless they receive clear instruction, including a physical demonstration, and have their inhaler technique checked regularly.54

Poor inhaler technique has been associated with worse outcomes in asthma and COPD. It can lead to poor asthma symptom control and overuse of relievers and preventers.48, 55, 53, 56, 57 In patients with asthma or COPD, incorrect technique is associated with a 50% increased risk of hospitalisation, increased emergency department visits and increased use of oral corticosteroids due to flare-ups.53

Correcting patients' inhaler technique has been shown to improve asthma control, asthma-related quality of life and lung function.58, 59

Common errors and problems with inhaler technique

Common errors with manually actuated pressurised metered dose inhalers include:54

  • failing to shake the inhaler before actuating
  • holding the inhaler in wrong position
  • failing to exhale fully before actuating the inhaler
  • actuating the inhaler too early or during exhalation (the medicine may be seen escaping from the top of the inhaler)
  • actuating the inhaler too late while inhaling
  • actuating more than once while inhaling
  • inhaling too rapidly (this can be especially difficult for chilren to overcome)
  • multiple actuations without shaking between doses.

Common errors for dry powder inhalers include:54

  • not keeping the device in the correct position while loading the dose (horizontal for Accuhaler and vertical for Turbuhaler)
  • failing to exhale fully before inhaling
  • failing to inhale completely
  • inhaling too slowly and weakly
  • exhaling into the device mouthpiece before or after inhaling
  • failing to close the inhaler after use
  • using past the expiry date or when empty.

Other common problems include:

  • difficulty manipulating device due to problems with dexterity (e.g. osteoarthritis, stroke, muscle weakness)
  • inability to seal the lips firmly around the mouthpiece of an inhaler or spacer
  • inability to generate adequate inspiratory flow for the inhaler type
  • failure to use a spacer when appropriate
  • use of incorrect size mask
  • inappropriate use of a mask with a spacer in older children.

How to improve patients’ inhaler technique

Patients’ inhaler technique can be improved by brief education, including a physical demonstration, from a health professional or other person trained in correct technique.54 The best way to train patients to use their inhalers correctly is one-to-one training by a healthcare professional (e.g. nurse, pharmacist, GP, specialist), that involves both verbal instruction and physical demonstration.60, 48, 61, 62 Patients do not learn to use their inhalers properly just by reading the manufacturer's leaflet.61 An effective method is to assess the individual's technique by comparing with a checklist specific to the type of inhaler, and then, after training in correct technique, to provide written instructions about errors (e.g. a sticker attached to the device).46, 59

The National Asthma Council information paper on inhaler technique includes checklists for correct technique with all common inhaler types used in asthma or COPD.

Inhaler technique must be rechecked and training must be repeated regularly to help children and adults maintain correct technique.58, 48, 49 

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References

  1. van Asperen PP, Mellis CM, Sly PD, Robertson C. The role of corticosteroids in the management of childhood asthma. The Thoracic Society of Australia and New Zealand, 2010. Available from: http://www.thoracic.org.au/clinical-documents/area?command=record&id=14
  2. Brand PL, Baraldi E, Bisgaard H, et al. Definition, assessment and treatment of wheezing disorders in preschool children: an evidence-based approach. Eur Respir J. 2008; 32: 1096-1110. Available from: http://erj.ersjournals.com/content/32/4/1096.full
  3. Merck, Sharp and Dohme Australia Pty Ltd. Product Information: Singulair (montelukast sodium) Tablets. Therapeutic Goods Administration, Canberra, 2013. Available from: https://www.ebs.tga.gov.au/
  4. National Asthma Council Australia. Leukotriene receptor antagonists in the management of childhood asthma. National Asthma Council Australia, Melbourne, 2010. Available from: http://www.nationalasthma.org.au/publication/ltras-their-role-in-childhood-asthma
  5. Ducharme FM. Addition of anti-leukotriene agents to inhaled corticosteroids for chronic asthma. Cochrane Database Syst Rev. 2004; Issue 1: CD003133. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003133.pub2/full
  6. Szefler SJ, Baker JW, Uryniak T, et al. Comparative study of budesonide inhalation suspension and montelukast in young children with mild persistent asthma. J Allergy Clin Immunol. 2007; 120: 1043-50. Available from: http://www.jacionline.org/article/S0091-6749(07)01726-5/fulltext
  7. Bisgaard H, Zielen S, Garcia-Garcia ML, et al. Montelukast reduces asthma exacerbations in 2- to 5-year-old children with intermittent asthma. Am J Respir Crit Care Med. 2005; 171: 315-322. Available from: http://ajrccm.atsjournals.org/content/171/4/315.long
  8. Pelkonen AS, Malmström K, Sarna S, et al. The effect of montelukast on respiratory symptoms and lung function in wheezy infants. Eur Respir J. 2013; 41: 664-670. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23060628
  9. Robertson CF, Price D, Henry R, et al. Short-course montelukast for intermittent asthma in children: a randomized controlled trial. Am J Respir Crit Care Med. 2007; 175: 323-329. Available from: http://ajrccm.atsjournals.org/content/175/4/323.long
  10. Fogel RB, Rosario N, Aristizabal G, et al. Effect of montelukast or salmeterol added to inhaled fluticasone on exercise-induced bronchoconstriction in children. Ann Allergy Asthma Immunol. 2010; 104: 511-517. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20568384
  11. Lipworth BJ, Basu K, Donald HP, et al. Tailored second-line therapy in asthmatic children with the Arg(16) genotype. Clin Sci (Lond). 2013; 124: 521-528. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23126384
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