Asthma Management Handbook

Administering inhaled medicines correctly in children

Recommendations

For babies and 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.

How this recommendation was developed

Adapted from existing guidance

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

  • Brand et al. 2008 1

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).

Advise patients and parents to wash standard plastic spacers (e.g. Able Spacer Universal, Breath-A-Tech, Volumatic) 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.

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.

Note: Priming or washing spacers to reduce electrostatic charge before using for the first time is only necessary for standard plastic spacers (e.g. Able Spacer Universal, Breath-A-Tech, Volumatic). It is not necessary for antistatic polymer spacers (e.g. Able A2A, AeroChamber Plus, Breathe Eazy, La Petite E-Chamber, La Grande E-Chamber, Space Chamber, OptiChamber Diamond), or disposable cardboard spacers.

Table. Types of spacers

Name

Material

Cleaning necessary

Priming necessary*

Able A2A

Antistatic polymer

Yes

No

Able Spacer Universal

Plastic

Yes

Yes

AeroChamber Plus

Polycarbonate polyurethane

Yes

No

Breath-A-Tech

Plastic

Yes

Yes

Breathe Eazy

Polycarbonate polyurethane

Yes

No

DispozABLE

Cardboard

No

No

La Grande E-Chamber

Polycarbonate polyurethane

Yes

No

LiteAire

Cardboard

No

No

La Petite E-Chamber

Polycarbonate polyurethane

Yes

No

OptiChamber Diamond

Thermoplastic polymer

Yes

No

Space Chamber

Polypropylene

Yes

No

Volumatic

Plastic

Yes

Yes

* Before first use only, by either of these methods:

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

  • Actuating medicine: 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.)

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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, 19952
  • Brand et al. 20081
  • Dompeling et al. 20013
  • National Asthma Council Australia, 20084

For patients using standard plastic spacers (e.g. Able Spacer Universal, Breath-A-Tech, Volumatic) or antistatic polymer spacers (e.g. Able A2A, AeroChamber Plus, Breathe Eazy, La Petite E-Chamber, La Grande E-Chamber, OptiChamber Diamond), advise patients and parents to clean the spacer monthly 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.

Note: 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.

Table. Types of spacers

Name

Material

Cleaning necessary

Priming necessary*

Able A2A

Antistatic polymer

Yes

No

Able Spacer Universal

Plastic

Yes

Yes

AeroChamber Plus

Polycarbonate polyurethane

Yes

No

Breath-A-Tech

Plastic

Yes

Yes

Breathe Eazy

Polycarbonate polyurethane

Yes

No

DispozABLE

Cardboard

No

No

La Grande E-Chamber

Polycarbonate polyurethane

Yes

No

LiteAire

Cardboard

No

No

La Petite E-Chamber

Polycarbonate polyurethane

Yes

No

OptiChamber Diamond

Thermoplastic polymer

Yes

No

Space Chamber

Polypropylene

Yes

No

Volumatic

Plastic

Yes

Yes

* Before first use only, by either of these methods:

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

  • Actuating medicine: 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.)

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Close
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, 19952
  • Brand et al. 20081
  • Dompeling et al. 20013
  • National Asthma Council Australia, 20084

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

How this recommendation was developed

Consensus

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

For children taking inhaled corticosteroids, recommend:

  • to rinse the mouth with water and spit after inhaling the last dose, to minimise the amount of medicine deposited in the oropharynx (particularly important if using a dry-powder inhaler)
  • to use 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. 2010 5

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

How this recommendation was developed

Adapted from existing guidance

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

  • Global Initiative for Asthma, 2009 6

More information

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.78

High rates of incorrect inhaler use among children with asthma and adults with asthma or COPD have been reported,9, 10, 11, 12, 13 even among regular users.14 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.15

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.9, 16, 14, 17, 18 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.14

Correcting patients' inhaler technique has been shown to improve asthma control, asthma-related quality of life and lung function.19, 20

Common errors and problems with inhaler technique

Common errors with manually actuated pressurised metered dose inhalers include:15

  • 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:15

  • 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.15 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.21, 9, 22, 23 Patients do not learn to use their inhalers properly just by reading the manufacturer's leaflet.22 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).7, 20

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.19, 9, 10 

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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.1 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.24

Dry-powder inhalers are usually ineffective for preschool children because they cannot generate sufficient inspiratory air flow.1

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.1 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.25 The inhaler design may improve spacer technique,25 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.1 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).26 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.27

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.24 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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Administration of inhaled medicines in children: 6 years and over

School-aged children (depending on the child’s age, ability, and with individualised training) can correctly use a range of inhaler types,28 including manually actuated pressurised metered-dose inhalers with spacers,29 breath-actuated pressurised metered-dose inhalers (e.g. Autohaler), and dry-powder inhalers (e.g. Accuhaler, Turbuhaler).2930

A pressurised metered-dose inhaler and spacer is an appropriate first choice for most children.28

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

School-aged children are unlikely to use their inhaler device correctly without careful training.31

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Preparation of new spacers before first use

Electrostatic surface charge on new standard plastic spacers (e.g. Able Spacer Universal, Breath-A-Tech, Volumatic) reduces the proportion of medicine available for delivery to the airway. This charge can be reduced by washing the plastic spacer in dishwashing liquid and allowing it to air dry or drip-dry without wiping (i.e. suds intact).1

Alternatively, priming the spacer by actuating the device several times into the spacer also overcomes the charge, but this wastes medicine. The optimal number of actuations for priming is not known and the findings of in vitro studies vary widely. One study (using older, CFC-based formulations of asthma medicines) reported that up to 40 actuations fired into a new plastic spacer overcame the effect of the electrostatic charge.2 Others have concluded that the electrostatic charge on plastic spacers does not reduce in vivo efficacy of bronchodilator therapy in children with asthma.3 The number of actuations necessary may be known when the results of recent studies become available.

When a new standard plastic spacer must be used immediately (e.g. for a person with asthma symptoms), patients, parents and carers should follow the manufacturer's priming instructions. In hospitals and emergency departments, a new spacer that has not been pre-treated by washing can be primed using multiple (at least 10) puffs of salbutamol. (This is an arbitrary number of actuations in the absence of evidence that would enable a precise guideline.)

Disposable cardboard spacers and antistatic polymer spacers (e.g. Able A2A, AeroChamber Plus, Breathe Eazy, La Petit E-Chamber, La Grande E-Chamber, OptiChamber Diamond) do not have this problem.1

Note: The term 'priming' is also used for the preparation process that is necessary for new pressurised metered-dose inhalers that have not been used for more than a week. This involves first actuating the inhaler into the air (away from the patient). Users should follow the manufacturer’s instructions for the particular brand of inhaler, which specify the number of actuations required.

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References

  1. 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
  2. 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
  3. 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
  4. National Asthma Council Australia. Inhaler technique in adults with asthma or COPD. An information paper for health professionals. National Asthma Council Australia, Melbourne, 2008. Available from: http://www.nationalasthma.org.au/publication/inhaler-technique-in-adults-with-asthma-or-copd
  5. 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
  6. Global Initiative for Asthma (GINA). Global strategy for the diagnosis and management of asthma in children 5 years and younger. GINA, 2009. Available from: http://www.ginasthma.org/
  7. Basheti IA, Armour CL, Bosnic-Anticevich SZ, Reddel HK. 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
  8. Bosnic-Anticevich, S. Z., Sinha, H., So, S., Reddel, H. K.. Metered-dose inhaler technique: the effect of two educational interventions delivered in community pharmacy over time. The Journal of asthma : official journal of the Association for the Care of Asthma. 2010; 47: 251-6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20394511
  9. Price, D., Bosnic-Anticevich, S., Briggs, A., et al. Inhaler competence in asthma: common errors, barriers to use and recommended solutions. Respiratory medicine. 2013; 107: 37-46. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23098685
  10. 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. The Journal of asthma : official journal of the Association for the Care of Asthma. 2015; 52: 838-45. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20394511
  11. Lavorini, F., Magnan, A., Dubus, J. C., et al. Effect of incorrect use of dry powder inhalers on management of patients with asthma and COPD. Respiratory medicine. 2008; 102: 593-604. Available from: https://www.ncbi.nlm.nih.gov/pubmed/18083019
  12. Federman, A. D., Wolf, M. S., Sofianou, A., et al. Self-management behaviors in older adults with asthma: associations with health literacy. Journal of the American Geriatrics Society. 2014; 62: 872-9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24779482
  13. 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 primary care respiratory medicine. 2014; 24: 14034. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25188403
  14. Melani AS, Bonavia M, Cilenti V, et al. Inhaler mishandling remains common in real life and is associated with reduced disease control. Respir Med. 2011; 105: 930-8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21367593
  15. National Asthma Council Australia. Inhaler technique for people with asthma or COPD. National Asthma Council Australia, Melbourne, 2016. Available from: https://www.nationalasthma.org.au/living-with-asthma/resources/health-professionals/information-paper/hp-inhaler-technique-for-people-with-asthma-or-copd
  16. Bjermer, L.. The importance of continuity in inhaler device choice for asthma and chronic obstructive pulmonary disease. Respiration; international review of thoracic diseases. 2014; 88: 346-52. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25195762
  17. Haughney, J., Price, D., Barnes, N. C., et al. Choosing inhaler devices for people with asthma: current knowledge and outstanding research needs. Respiratory medicine. 2010; 104: 1237-45. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20472415
  18. Giraud, V., Roche, N.. Misuse of corticosteroid metered-dose inhaler is associated with decreased asthma stability. The European respiratory journal. 2002; 19: 246-51. Available from: https://www.ncbi.nlm.nih.gov/pubmed/11866004
  19. Basheti IA, Reddel HK, Armour CL, Bosnic-Anticevich SZ. Improved asthma outcomes with a simple inhaler technique intervention by community pharmacists. J Allergy Clin Immunol. 2007; 119: 1537-8. Available from: http://www.jacionline.org/article/S0091-6749(07)00439-3/fulltext
  20. Giraud, V., Allaert, F. A., Roche, N.. Inhaler technique and asthma: feasability and acceptability of training by pharmacists. Respiratory medicine. 2011; 105: 1815-22. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21802271
  21. Basheti, I. A., Reddel, H. K., Armour, C. L., Bosnic-Anticevich, S. Z.. Counseling about turbuhaler technique: needs assessment and effective strategies for community pharmacists. Respiratory care. 2005; 50: 617-23. Available from: https://www.ncbi.nlm.nih.gov/pubmed/15871755
  22. 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
  23. 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
  24. Schuh, S., Johnson, D. W., Stephens, D., et al. Comparison of albuterol delivered by a metered dose inhaler with spacer versus a nebulizer in children with mild acute asthma. The Journal of pediatrics. 1999; 135: 22-7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/10393599
  25. Schultz A, Sly PD, Zhang G, et al. Incentive device improves spacer technique but not clinical outcome in preschool children with asthma. J Paediatr Child Health. 2012; 48: 52-6. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1440-1754.2011.02190.x/full
  26. National Asthma Council Australia. Kids' First Aid for Asthma. National Asthma Council Australia, Melbourne, 2011. Available from: http://www.nationalasthma.org.au/first-aid
  27. Schultz A, Le Souëf TJ, Venter A, et al. Aerosol inhalation from spacers and valved holding chambers requires few tidal breaths for children. Pediatrics. 2010; 126: e1493-8. Available from: http://pediatrics.aappublications.org/content/126/6/e1493.long
  28. Ram FS, Brocklebank DD, 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: CD002158. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002158/full
  29. British Thoracic Society (BTS), Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the Management of Asthma. A national clinical guideline. BTS, SIGN, Edinburgh, 2012. Available from: https://www.brit-thoracic.org.uk/guidelines-and-quality-standards/asthma-guideline/
  30. Nikander K, Turpeinen M, Pelkonen AS, et al. True adherence with the Turbuhaler in young children with asthma. Arch Dis Child. 2011; 96: 168-73. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21097795
  31. Sleath B, Ayala GX, Gillette C, et al. Provider demonstration and assessment of child device technique during pediatric asthma visits. Pediatrics. 2011; 127: 642-8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21444594