Asthma Management Handbook

Choosing an inhaler device to suit the individual

Recommendations

When prescribing inhaled medicines, make sure the inhaler is appropriate for the patient's age, developmental stage, cognitive function, inspiratory effort and dexterity.

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

Table. Considerations for choice of inhaler device type when prescribing inhaled medicines

Clinical situation

Consideration

Acute asthma (all patients) Recommend use of spacer when using reliever via pMDI for acute asthma

Any patient using a pMDI for an inhaled corticosteroid

Recommend use of a spacer every time (except for breath-actuated pMDIs)

Infants and small children

Use a spacer with a facemask

Poor manual dexterity (e.g. weak hands or arthritis)

Consider either of:

  • a Haleraid device with relevant pMDIs (available for salbutamol, fluticasone, fluticasone/salmeterol)
  • a breath-actuated inhaler

Difficulty connecting spacer to pMDI (e.g. elderly patient with weakness or poor coordination)

Leave spacer connected: pharmacist can attach spacer to inhaler each time canister is replaced, and leave attached until medicine is used up. (If patient uses more than one pMDI, provide a separate spacer for each device.

Consider a breath-actuated inhaler.

Inability to form a good seal around the mouthpiece of the inhaler or spacer (e.g. person with cognitive impairment or facial weakness)

Consider a spacer plus age-appropriate facemask

Difficulty speaking or reading English

Give a physical demonstration

Use videos

Use an interpreter or provide written instructions in the person’s first language

Using multiple inhalers

Choose the same type for each medicine, if possible, to avoid confusion

If not possible, train person in the correct inhaler technique for each of their devices, emphasising any key differences (e.g. speed of inhalation, shake pMDIs but not dry-powder inhalers)

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For patients who may find it difficult to use an inhaler (e.g. older patients with arthritis or weakness or people with disabilities), check the person’s technique to work out which inhaler type will be easiest to use. 

How this recommendation was developed

Consensus

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

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More information

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.

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Administration of inhaled medicines in children: 1-5 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. 

Types of inhalers suitable for preschool children

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 actuating the device.1 Note that breath-actuated pressurised metered-dose inhalers cannot be used with a spacer.

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

Drug delivery is very variable in young children with any type of inhaler, including pressurised metered dose inhalers and spacers.20 Filter studies have shown high day-to-day variability in delivered doses 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.

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

Pressurised metered-dose inhalers plus spacers for relievers

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.2

When administering salbutamol to relieve asthma symptoms in a preschool child, the standard recommendation is to shake the inhaler, actuate one puff at a time into the spacer and have the child take 4–6 breaths in and out of the spacer (tidal breathing).3 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.4

Face masks for infants

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.2 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

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).5, 6, 7, 8, 9

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.7

School-aged children are unlikely to use their inhaler device correctly without careful training and repeated checking.10

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Choosing inhaler devices for older adults

Incorrect inhaler technique is common among older people with asthma or COPD, whether using a pressurised metered-dose inhaler or a dry-powder inhaler, particularly with those with more severe airflow limitation.1112, 1314, 15, 16,17

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

Inhaler devices should be used in favour of nebulisers wherever possible, just as for younger adults.12 The use of nebulisers is more costly, carries a greater risk of side-effects and increases the risk of transmitting infections to other patients or to health workers. The use of ipratropium bromide via nebulisers with loose-fitting masks has been associated with pupil dilatation, blurred vision and acute glaucoma.18 The use of inhaled corticosteroids by nebuliser can be associated with increased risk of skin atrophy or cataract if the seal around the mask is not good. In addition, in practice, many patients do not maintain their nebuliser adequately (e.g. they do not clean or change the bowl as often as recommended, increasing the chance of ineffective treatment or contamination).

Problems for older patients using inhalers

Common problems for older people include:13161920, 2122, 23

  • inadequate inspiratory flow (particularly among those with COPD), which limits ability to use dry-powder inhalers or pressurised metered-dose inhalers properly
  • difficulty connecting a pressurised metered-dose inhaler to a spacer
  • inability to coordinate breathing in with actuating a pressurised metered-dose inhaler
  • inability to actuate a pressurised metered-dose inhaler due to arthritis or weakness of the hands
  • inability to achieve a firm seal around the mouthpiece when using inhalers alone or with a spacer (particularly for patients with cognitive impairment, facial weakness, or who are missing teeth).

About half of all older people with asthma or COPD are prescribed more than one inhaler device.24 As the number of prescribed devices increase, the frequency of error also increases.25

Inhaler options for older adults

Patients with arthritis may find it easier to use an aid (e.g. Haleraid hand-grip device) to help them actuate their inhaler, or use a breath-actuated inhaler. Mechanical difficulties can usually be overcome by checking each individual’s technique and helping the person identify which inhaler they can use best among those available for the required medicine.

For some patients, a breath-actuated pressurised metered-dose inhaler (e.g. Autohaler) or breath-actuated dry-powder inhaler (e.g. Turbuhaler or Accuhaler) may be easier to use than pressurised metered-dose inhalers.2021 However, some patients (e.g. those with severe COPD) may be unable to achieve a high enough inspiratory rate to actuate dry-powder inhalers (e.g. Accuhaler or Turbuhaler).21, 23 With a breath-actuated inhaler, adequate lung doses of inhaled corticosteroids may be achieved despite poor technique.26

Older people with asthma can acquire and retain appropriate technique after specific instruction, but this instruction needs to be repeated regularly to reinforce correct inhaler technique,12 just as for young people. People with cognitive impairment are likely to have problems retaining skills after instruction in the use of an inhaler.27

Table. Considerations when choosing inhaler devices for older patients

Problem

Solution

Reduced maximal inspiratory flow

Consider pMDI alone or with spacer

Avoid dry-powder inhalers

Reduced manual dexterity (e.g. due to osteoarthritis)

Consider a Haleraid with a pMDI, where relevant (salbutamol, fluticasone, fluticasone/salmeterol)

Consider pMDI with small-volume spacer or breath-actuated dry-powder inhaler

Inability to coordinate actuation and inhalation

Consider pMDI with spacer, breath-actuated pMDI or breath-actuated dry-powder inhaler

Avoid pMDI without spacer

Inability to form effective seal with lips around mouthpiece

Use spacer plus face mask

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References

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  2. 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
  3. National Asthma Council Australia. Kids' First Aid for Asthma. National Asthma Council Australia, Melbourne, 2011. Available from: http://www.nationalasthma.org.au/first-aid
  4. 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
  5. 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
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  14. van der Palen J, Klein JJ, Kerkhoff AH, et al. Inhalation technique of 166 adult asthmatics prior to and following a self-management program. J Asthma. 1999; 36: 441-7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/10461933
  15. Sestini P, Cappiello V, Aliani M, et al. Prescription bias and factors associated with improper use of inhalers. J Aerosol Med. 2006; 19: 127-36. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16796537
  16. Rees J. Methods of delivering drugs. BMJ. 2005; 331: 504-6. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1199035/
  17. Brennan VK, Osman LM, Graham H, et al. True device compliance: the need to consider both competence and contrivance. Respir Med. 2005; 99: 97-102. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15672856
  18. Gupta P, O'Mahony MS. Potential adverse effects of bronchodilators in the treatment of airways obstruction in older people: recommendations for prescribing. Drugs Aging. 2008; 25: 415-43. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18447405
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