Asthma Management Handbook

Administering inhaled medicines correctly in children

Recommendations

Check the child’s inhaler technique at each asthma consultation or when dispensing inhaled asthma medicines:

  • Have the child or parent demonstrate how the child uses the inhaler, while checking against a checklist of steps for that type of inhaler.
  • Demonstrate correct technique using a placebo device and correct any specific errors identified.
  • Have the child or parent repeat the demonstration to check they can now use the device correctly. If necessary, repeat instruction until the patient has all steps correct.
  • Provide the checklist as a reminder, and write down or highlight any steps that were done incorrectly (e.g. on a sticker attached to their inhaler).

Note: Watch the child/parent use the inhaler – don’t just ask if they think they know how to use it properly.

Checklists of steps, and videos demonstrating correct technique, for various types of inhalers are available on National Asthma Council Australia’s website.

How this recommendation was developed

Evidence-based recommendation

Based on literature search and formulated by multidisciplinary working group

Key evidence considered:

  • The Inhaler Error Steering Committee 20131
  • Basheti et al. 20082
  • Basheti et al. 20173
  • Crane et al. 20144
  • Giraud et al. 20115
  • Lavorini et al. 20146
  • Newman et al. 20147
  • Hesso et al. 20168

Last reviewed version 2.0

For children too young to use a mouthpiece (most children under 4 years), deliver inhaled medicines via a pressurised metered-dose inhaler and small-volume spacer with tightly fitting facemask.

Note: The child’s face should be washed after using inhaled corticosteroids.

How this recommendation was developed

Adapted from existing guidance

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

  • Brand et al. 20089

Last reviewed version 2.0

For children who are able to cooperate and understand how to seal their lips tightly around a spacer mouthpiece (usually those aged 4 years and over), deliver inhaled medicines via a pressurised metered-dose inhaler and small-volume spacer with a mouthpiece.

How this recommendation was developed

Consensus

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

Last reviewed version 2.0

For children using spacers made of plastic (e.g. Breath-A-Tech, Volumatic), advise parents to wash the spacer before first use to reduce electrostatic charge. This should be done by disassembling if necessary, washing in warm water and dishwashing detergent, then allowing to air dry without rinsing or wiping before carefully reassembling.

If a new plastic spacer must be used immediately, it can be primed by firing multiple (at least 10) puffs of medicine into the spacer. (This is an arbitrary number of actuations in the absence of evidence that would enable a precise guideline.) Patients should follow the manufacturer’s instructions.

Notes:
Priming or washing spacers to reduce electrostatic charge before using for the first time is only necessary for plastic spacers (e.g. Breath-A-Tech, Volumatic). Priming or washing is not necessary for polyurethane/antistatic polymer spacers (e.g. Able A2A, AeroChamber Plus, La Petite E-Chamber, La Grande E-Chamber) or disposable cardboard spacers (e.g. DispozABLE, LiteAire).

Table. Types of spacers

Name

Material

Cleaning necessary

Priming necessary
before first use*

Able A2A

Antistatic polymer

Yes

No

AeroChamber Plus

Polycarbonate polyurethane

Yes

No

Breath-A-Tech

Plastic

Yes

Yes

DispozABLE

Cardboard

No

No

La Grande E-Chamber

Polycarbonate polyurethane

Yes

No

LiteAire

Cardboard

No

No

La Petite E-Chamber

Polycarbonate polyurethane

Yes

No

Volumatic

Plastic

Yes

Yes

Washing: disassemble (if necessary), wash in warm water and dishwashing detergent, then allow to air dry without rinsing or wiping. Reassemble carefully.

Priming plastic spacers: wash and allow to dry (as above) before first use, to reduce static charge. If an unwashed plastic spacer needs to be used immediately, fire multiple (at least 10) actuations of medicine into the spacer, following manufacturer's instructions. (This is an arbitrary number of actuations in the absence of evidence that would enable a precise guideline.)

Last reviewed version 2.0

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How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to the following source(s):

  • Berg 199510
  • Brand et al. 20089
  • Dompeling et al. 200111
  • National Asthma Council Australia 201812

Last reviewed version 2.0

For children using standard plastic spacers (e.g. Breath-A-Tech, Volumatic) or polyurethane/antistatic polymer spacers (e.g. Able A2A, AeroChamber Plus, La Petite E-Chamber, La Grande E-Chamber), advise patients and parents to clean the spacer monthly (but not more often) and after the resolution of any respiratory tract infection.

To clean a spacer:

  • dismantle as per manufacturer’s instructions, if necessary
  • wash parts in warm water with liquid dishwashing detergent
  • allow to air dry without rinsing
  • reassemble carefully, if necessary.

Notes:
Do not dry spacers with a cloth or paper towel. Wiping can increase the electrostatic charge on the inside of the spacer, which can reduce the available dose.
Spacers become cloudy after use – this is normal and does not affect their use.

Table. Types of spacers

Name

Material

Cleaning necessary

Priming necessary
before first use*

Able A2A

Antistatic polymer

Yes

No

AeroChamber Plus

Polycarbonate polyurethane

Yes

No

Breath-A-Tech

Plastic

Yes

Yes

DispozABLE

Cardboard

No

No

La Grande E-Chamber

Polycarbonate polyurethane

Yes

No

LiteAire

Cardboard

No

No

La Petite E-Chamber

Polycarbonate polyurethane

Yes

No

Volumatic

Plastic

Yes

Yes

Washing: disassemble (if necessary), wash in warm water and dishwashing detergent, then allow to air dry without rinsing or wiping. Reassemble carefully.

Priming plastic spacers: wash and allow to dry (as above) before first use, to reduce static charge. If an unwashed plastic spacer needs to be used immediately, fire multiple (at least 10) actuations of medicine into the spacer, following manufacturer's instructions. (This is an arbitrary number of actuations in the absence of evidence that would enable a precise guideline.)

Last reviewed version 2.0

Asset ID: 98

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How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to the following source(s):

  • Berg 199510
  • Brand et al. 20089
  • Dompeling et al. 200111
  • National Asthma Council Australia 201812

Last reviewed version 2.0

When giving multiple puffs via a spacer, shake the inhaler, then fire one puff into the spacer and ask the child to take 4–6 breaths in and out of spacer after each puff.

Shake the inhaler again, and repeat.

How this recommendation was developed

Consensus

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

Last reviewed version 2.0

For children taking inhaled corticosteroids, recommend:

  • rinsing the mouth with water and spitting after inhaling the last dose, to minimise the amount of medicine deposited in the oropharynx
  • using a spacer (if using a manually-actuated pressurised metered-dose inhaler).
How this recommendation was developed

Adapted from existing guidance

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

  • van Asperen et al. 201013

Last reviewed version 2.0

Consider using a nebuliser only if a child cannot be taught to inhale medicine from a spacer.

How this recommendation was developed

Consensus

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

Last reviewed version 2.0

More information

Administration of inhaled medicines in children: 6 years and over

Parents, carers and children need training to use inhaler devices correctly, including inhaler technique, and care and cleaning of inhalers and spacers.

School-aged children (depending on the child’s age, ability, and with individualised training) can learn to use a range of inhaler types, including manually actuated pressurised metered-dose inhalers with spacers, breath-actuated pressurised metered-dose inhalers (e.g. Autohaler), and dry-powder inhalers (e.g. Accuhaler, Turbuhaler).14, 15, 16, 17, 18

Table. Types of inhaler devices for delivering asthma and COPD medicines Opens in a new window Please view and print this figure separately: http://www.asthmahandbook.org.au/table/show/75

A pressurised metered-dose inhaler and spacer is an appropriate first choice for most children.16

School-aged children are unlikely to use their inhaler device correctly without careful training and repeated checking.19

Last reviewed version 2.0

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Correct use of inhaler devices

Checking and correcting inhaler technique is essential to effective asthma management.

Most patients with asthma or COPD do not use their inhalers properly,1, 4-7 and most have not had their technique checked or corrected by a health professional.

Incorrect inhaler technique when using maintenance treatments increases the risk of severe flare-ups and hospitalisation for people with asthma or COPD.1, 4, 5, 14, 22, 23

Poor asthma symptom control is often due to incorrect inhaler technique.24, 25

Incorrect inhaler technique when using inhaled corticosteroids increases the risk of local side effects like dysphonia and oral thrush.

The steps for using an inhaler device correctly differ between brands. Checklists of correct steps for each inhaler type and how-to videos are available from the National Asthma Council website.

Last reviewed version 2.0

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References

  1. The Inhaler Error Steering Committee,, Price, D., Bosnic-Anticevich, S., et al. Inhaler competence in asthma: common errors, barriers to use and recommended solutions. Respir Med. 2013; 107: 37-46. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23098685
  2. Basheti, I A, Armour, C L, Bosnic-Anticevich, S Z, Reddel, H K. Evaluation of a novel educational strategy, including inhaler-based reminder labels, to improve asthma inhaler technique. Patient Educ Couns. 2008; 72: 26-33. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18314294
  3. Basheti, IA; Obeidat, NM; Reddel, HK;. Effect of novel inhaler technique reminder labels on the retention of inhaler technique skills in asthma: a single-blind randomized controlled trial.. NPJ Prim Care Respir Med. 2017; 27: 9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28184045
  4. Crane, M. A., Jenkins, C. R., Goeman, D. P., Douglass, J. A.. Inhaler device technique can be improved in older adults through tailored education: findings from a randomised controlled trial. NPJ Prim Care Respir Med. 2014; 24: 14034. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25188403
  5. Giraud, V., Allaert, F. A., Roche, N.. Inhaler technique and asthma: feasability and acceptability of training by pharmacists. Respir Med. 2011; 105: 1815-22. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21802271
  6. Lavorini, F.. Inhaled drug delivery in the hands of the patient. Journal of aerosol medicine and pulmonary drug delivery. 2014; 27: 414-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25238005
  7. Newman, S.. Improving inhaler technique, adherence to therapy and the precision of dosing: major challenges for pulmonary drug delivery. Expert opinion on drug delivery. 2014; 11: 365-78. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24386924
  8. Hesso, I., Gebara, S. N., Kayyali, R.. Impact of community pharmacists in COPD management: Inhalation technique and medication adherence. Respir Med. 2016; 118: 22-30. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27578467
  9. 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
  10. Berg E. In vitro properties of pressurized metered dose inhalers with and without spacer devices. J Aerosol Med. 1995; 8 Suppl 3: S3-10; discussion S11. Available from: http://www.ncbi.nlm.nih.gov/pubmed/10157897
  11. Dompeling E, Oudesluys-Murphy AM, Janssens HM, et al. Randomised controlled study of clinical efficacy of spacer therapy in asthma with regard to electrostatic charge. Arch Dis Child. 2001; 84: 178-182. Available from: http://adc.bmj.com/content/84/2/178.full
  12. National Asthma Council Australia,. Inhaler technique in adults with asthma or COPD. An information paper for health professionals. NACA, Melbourne, 2018. Available from: https://www.nationalasthma.org.au/living-with-asthma/resources/health-professionals/information-paper/hp-inhaler-technique-for-people-with-asthma-or-copd
  13. 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: https://www.thoracic.org.au/journal-publishing/command/download_file/id/25/filename/The_role_of_corticosteroids_in_the_management_of_childhood_asthma_-_2010.pdf
  14. Gillette, C., Rockich-Winston, N., Kuhn, J. A., et al. Inhaler technique in children with asthma: a systematic review. Acad Pediatr. 2016; 16: 605-15. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27130811
  15. Capanoglu, M., Dibek Misirlioglu, E., Toyran, M., et al. Evaluation of inhaler technique, adherence to therapy and their effect on disease control among children with asthma using metered dose or dry powder inhalers. J Asthma. 2015; 52: 838-45. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26037396
  16. Ram, F S F, Brocklebank, D D M, White, J, et al. Pressurised metered dose inhalers versus all other hand-held inhaler devices to deliver beta-2 agonist bronchodilators for non-acute asthma. Cochrane Database Syst Rev. 2002; Issue 2: .
  17. Nikander, K, Turpeinen, M, Pelkonen, A S, et al. True adherence with the Turbuhaler in young children with asthma. Arch Dis Child. 2011; 96: 168-173.
  18. Pedersen, S., Mortensen, S.. Use of different inhalation devices in children. Lung. 1990; 168 Suppl: 653-7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/2117175
  19. Sleath, B, Ayala, G X, Gillette, C, et al. Provider demonstration and assessment of child device technique during pediatric asthma visits. Pediatrics. 2011; 127: 642-648.