Use and care of spacers
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.
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.
Ask patients to bring their spacer with them to be checked every 6–12 months. Check that there are no cracks and that the valve is working.
- How this recommendation was developed
Based on clinical experience and expert opinion (informed by evidence, where available).
- Preparation of new spacers before first use
Spacers are made of plastic, antistatic polymer/polycarbonate polyurethane, or cardboard.
Plastic spacers (e.g. Breath-A-Tech, Volumatic)
Electrostatic surface charge on new spacers made of plastic (e.g. 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 rinsing or wiping.2
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.1 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 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 (e.g. DispozABLE, LiteAire) and polyurethane/antistatic polymer spacers (e.g. Able A2A, AeroChamber Plus, La Petite E-Chamber, La Grande E-Chamber) do not require preparation before first use.2
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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- Technical notes: pressurised metered-dose inhalers with spacers
Manufacturers of most pressurised metered-dose delivery devices recommend shaking the device before actuating. The physical characteristics of each formulation, including the effects of shaking, differ widely,5 but for simplicity it is best always to recommend shaking of pressurised metered-dose inhalers.
Pressurised metered-dose inhalers (except for those that are breath-actuated) can be used with a spacer. When a spacer is used with a pressurised metered-dose inhaler, delivery of the medicine to the patient’s airways is maximised when the patient takes a slow, deep breath from the spacer after each actuation.6, 7 Multiple actuations of a pressurised metered-dose inhaler into a spacer can reduce the amount of respirable medicine available because aerosol particles can agglomerate into larger particles or become attached to the spacer walls.6
Therefore, the ideal way to deliver inhaled medicines via pressurised metered-dose inhaler and spacer is to shake the device, ask the person to breathe out all the way into the spacer, actuate a single puff into the spacer, and have the person immediately take a slow deep breath from the spacer, then hold their breath for 5 seconds. This process should be repeated until the total intended number of actuations is taken. Patients should be trained to follow these instructions when using their inhalers. Inhaling slowly with a single breath maximises delivery of the medicine to the lungs and minimises deposition in the upper airways when using a manually actuated pressurised metered-dose inhaler with or without a spacer, or when using a breath-actuated pressurised metered-dose inhaler.8 However, slow breathing may not be possible for patients with acute asthma. Tidal breathing through the spacer (e.g. four breaths in and out without removing the spacer) is used in acute asthma and for very young children. First aid instructions should include how to use inhaler and spacer.
In practice, optimal delivery of inhaled medicines involves a balance between maximising the proportion of respirable medicine and maximising efficiency of inhalation by the patient within real-world constraints. The optimal delivery of salbutamol in real-world circumstances is not well defined. For day-to-day use of salbutamol, most adults gain sufficient relief from symptoms when using a pressurised metered-dose inhaler on its own. A spacer may only be needed during a flare-up. By contrast, the use of a spacer is always recommended for inhaled corticosteroids delivered by manually actuated pressurised metered-dose inhalers, to reduce the risk of local adverse effects and increase delivery to the airways.
Many available in vitro studies of aerosol particle deposition in the airways were performed using older CFC-propelled formulations, which are now obsolete. Similar studies have not been performed for current non-CFC pressurised metered-dose inhalers.
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- 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
- 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
- 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
- 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
- Cyr TD, Graham SJ, Li KY, Levering EG. Low first-spray drug content in albuterol metered-dose inhalers. Pharm Res. 1991; 8: 658-660. Available from: http://link.springer.com/article/10.1023/A:1015825311750
- Barry PW, O'Callaghan C. Multiple actuations of salbutamol MDI into a spacer device reduce the amount of drug recovered in the respirable range. Eur Respir J. 1994; 7: 1707-1709. Available from: http://www.ncbi.nlm.nih.gov/pubmed/7995401
- Rau JL, Restrepo RD, Deshpande V. Inhalation of single vs multiple metered-dose bronchodilator actuations from reservoir devices : An in vitro study. Chest. 1996; 109: 969-974. Available from: http://www.ncbi.nlm.nih.gov/pubmed/8635379
- Laube BL, Janssens HM, de Jongh FHC, et al. What the pulmonary specialist should know about the new inhalation therapies. Eur Respir J. 2011; 37: 1308-1417. Available from: http://erj.ersjournals.com/content/37/6/1308.full