Patient education: Asthma inhaler techniques in children (Beyond the Basics)
- Robert H Moore, MD
Robert H Moore, MD
- Associate Professor of Pediatrics
- Baylor College of Medicine
- Section Editors
- George B Mallory, MD
George B Mallory, MD
- Section Editor — Pediatric Pulmonology
- Associate Professor of Pediatrics
- Baylor College of Medicine
- Robert A Wood, MD
Robert A Wood, MD
- Editor-in-Chief — Allergy and Immunology
- Section Editor — Pediatric Allergy
- Professor of Pediatrics
- Johns Hopkins University School of Medicine
ASTHMA INHALER OVERVIEW
Inhaled medications are vital in the treatment of childhood asthma, although they are only effective if they are used properly. Using an inhaler correctly delivers the medication to the lungs and leads to a better response. If the medication is used incorrectly, little or none of it reaches the lungs.
Unfortunately, many people with asthma do not use the best inhaler technique. Almost everyone, including children, can learn proper inhaler technique with training and practice.
This article discusses the use of asthma inhalers in children. Other topics about asthma in children are available separately. (See "Patient education: Asthma symptoms and diagnosis in children (Beyond the Basics)" and "Patient education: Asthma treatment in children (Beyond the Basics)" and "Patient education: How to use a peak flow meter (Beyond the Basics)" and "Patient education: Trigger avoidance in asthma (Beyond the Basics)".)
Articles are also available for adults with asthma. (See "Patient education: Asthma treatment in adolescents and adults (Beyond the Basics)" and "Patient education: How to use a peak flow meter (Beyond the Basics)" and "Patient education: Asthma inhaler techniques in adults (Beyond the Basics)" and "Patient education: Asthma and pregnancy (Beyond the Basics)".)
METERED DOSE ASTHMA INHALERS
Metered dose inhalers (MDIs) are used to deliver a variety of inhaled medications. An MDI consists of a pressurized canister, a metering valve and stem, and a mouthpiece actuator (picture 1).
The inhaler canister contains the medicine and other chemicals that help to deliver the medication to the lungs. Previously, inhalers contained a chemical known to damage the ozone layer. As a result, most inhalers in the United States were reformulated after December 2008. The new inhalers use a chemical called hydrofluoroalkane (HFA) to deliver the medication to the lungs. HFA devices may have a different taste compared with the previous inhalers, and the spray may feel softer. However, this does not mean that the medicine is not reaching your lungs.
In addition, HFA inhalers need to be cleaned and primed to prevent medication build up and blockage. Each manufacturer will provide instructions about how to use their inhaler. These instructions should be reviewed carefully. (See 'How to use an MDI' below.)
HFA inhalers may be more expensive than the older inhaler. Talk to your healthcare provider if you have difficulty paying for your medications because assistance programs may be available.
How to use an MDI — Each MDI manufacturer has specific instructions for using their inhaler; the following are general instructions.
When using an MDI for the FIRST time (with or without a spacer or valved holding chamber), prepare the inhaler first:
●Shake the inhaler for five seconds.
●Prime the inhaler by pressing down the canister with the index finger to release the medication. Hold away from the face to prevent medication from getting into the eyes. Press the canister down again three times.
After you use an inhaler for the first time, it does not need to be primed again unless you do not use it for two weeks or more.
When using a facemask, it is important to hold the mask snugly against the child's face; even a small leak can significantly reduce the amount of medication that reaches the lungs. Flexible masks appear to provide a better seal than rigid masks.
Cleaning the MDI — HFA inhalers must be cleaned on a regular basis to prevent medication build up and blockages. Most manufacturers recommend cleaning the mouthpiece at least once per week. To clean:
●Remove the medication canister and cap from the mouthpiece. Do not wash the canister or immerse it in water.
●Run warm tap water through the top and bottom of the plastic mouthpiece for 30 to 60 seconds.
●Shake off excess water and allow the mouthpiece to dry completely (overnight is recommended).
●If you need the inhaler before the mouthpiece is dry, shake off excess water, replace the canister, and test spray two times (away from the face).
Spacer devices — Using a spacer device with an inhaler can help to deliver more medication to the lungs and dramatically decrease the amount of medicine deposited in the back of the mouth and the tongue. A spacer holds the medicine in a chamber after it has been released from the inhaler, allowing the child to inhale slowly and deeply once or twice (picture 2 and figure 1).
A spacer is recommended for any child who has difficulty squeezing the canister and inhaling at the right time (particularly children less than five to six years). Spacers are recommended for all children who use inhaled glucocorticoids.
There are many spacers on the market, although little is known about the benefit of one type versus another. In general, larger-sized (100 to 700 mL) spacers appear to be more effective than smaller ones. Proper technique and frequent cleaning are important. (See 'Cleaning the spacer' below.)
Valved-holding chambers — The valved-holding chamber is a specialized spacer that incorporates a one-way valve. This allows the child to breathe in and out of a mouthpiece or face mask. With traditional spacers, the child must breathe in through the spacer and breathe out away from the spacer. The child often needs to take five to six breaths to inhale all of the medication.
Valved-holding chamber spacers are appropriate for infants and young children. However, this type of spacer may not be appropriate for newborns and very small infants, because they cannot reliably inhale with enough force to open the valves.
Preparing a new spacer — Before using a spacer for the first time, it should be treated to reduce the electrostatic charge. This can be done by washing the spacer in a dilute solution of dishwashing detergent and warm water. The device should be air dried without rinsing out the detergent. Some spacers (eg, the Pari Vortex) are electrostatic free, and no preparation is needed.
Cleaning the spacer — Although the powder residue that is deposited in the chamber is not harmful, the spacer should be cleaned periodically. Wash it with warm water and dishwashing detergent; washing with water alone causes an electrostatic charge to develop, reducing the effectiveness of the spacer.
How to get the most out of an inhaler — Several common mistakes can prevent inhaled medications from getting to the lungs. The following tips can help to get the most out of an MDI.
●Remember to take the cap off the mouthpiece.
●Be sure there is medication in the canister. (See 'Determine when an inhaler is empty' below.)
●Inhale through the mouth, not the nose.
●Take a slow, deep breath at the same time you press down on the medication canister.
●If you have difficulty timing your breath while spraying the medication, there are inhalers that automatically release the medication when you take a breath (eg, Maxair Autohaler). Another alternative is a dry powder inhaler (DPI). (See 'Dry powder asthma inhalers' below.)
Metered dose inhaler versus nebulizer — Nebulizers use compressed air to change a medication from liquid form to a fine spray that can be inhaled through a mask or mouthpiece (figure 1). Nebulizers may be preferred to MDIs for some children who are too ill or too young to use a handheld device or in situations where large drug doses are necessary.
However, studies suggest that inhalers can be used to effectively deliver medications to the lungs, even in infants . Therefore, young age and small size does not mean that a nebulizer is required. Giving one or more doses of a short-acting bronchodilator via inhaler with a spacer and facemask is at least as effective as, and possibly better than, giving the same medication by nebulizer in most infants and children . (See 'Spacer devices' above.)
BREATH ACTUATED ASTHMA INHALER
For children who have difficulty timing their breath and spraying the medication, there are inhalers that automatically release the medication when the child breathes in (eg, Maxair Autohaler). The disadvantage of this device is that some children may not be able to inhale forcefully enough to trigger the drug's release, especially during an asthma attack.
DRY POWDER ASTHMA INHALERS
An alternative to metered dose inhalers (MDIs) is a dry powder inhaler (DPI). DPIs eliminate the need to coordinate taking a breath and squeezing the canister. DPIs deliver a fine powder to the lungs when the child breathes in (picture 3). Children who use DPIs need to inhale more forcefully than with a traditional aerosol inhaler. Thus, DPIs may not be suitable for some children who are less than six years or older children with nerve or muscle weakness. Also, the child must not blow (exhale) directly into the device before breathing in, as this can scatter the medicine before it is inhaled.
Examples include the long-acting rescue medication Foradil; the controller medications Asmanex, Flovent, and Pulmicort Flexhaler; and the combination inhaler Advair. DPIs may contain tiny amounts of lactose, which is a type of sugar.
DPIs come in two main types:
●Multiple-dose devices, which contain up to 200 doses.
●Single-dose devices (Spiriva Handihaler, TOBI Podhaler), which require the person to place a capsule in the device immediately before each treatment. DPI capsules should NOT be swallowed.
Instructions for using a DPI are included in the table (table 3A-B).
Cleaning the DPI — Most DPIs should not be washed with soap and water. The mouthpiece can be cleaned with a dry cloth approximately once per week. Consult the instructions with your inhaler for further information.
ASTHMA ATTACK CARE AND PREVENTION
Patients with asthma should work with their healthcare provider to develop an asthma action plan that is successful in treating and preventing asthma attacks. Depending upon the severity of your child's asthma, the treatment regimen may include regular visits with the provider, use of one or more medications, avoiding asthma triggers, and home symptom monitoring. At each visit, the child and/or parent should demonstrate how they use an inhaler to ensure that the correct technique is used.
Keep an adequate supply of medication — A child should always have an adequate supply of his or her medication(s). This includes verifying that medication is not expired and that an inhaler is available at home, at school, in the car, and when out with family or friends.
Determine when an inhaler is empty — It is not always possible to determine when an inhaler is empty by shaking it, because some propellant remains in the canister after all of the medication has been used. A few inhalers now have dose counters to track the amount of medication used, including Ventolin-HFA and Flovent (picture 4). Ask your healthcare provider if a counter is available on your inhaler.
If you do not have a counter, but you use your inhaler on a regular basis (eg, two puffs once per day), you should refill your prescription once per month and throw away the old inhaler.
In the past, you may have been told to drop the canister into a bowl of water and see how it floats. However, this method is not reliable, and it is no longer recommended. Spraying the inhaler is also not recommended, because even an empty inhaler will continue to spray.
WHERE TO GET MORE INFORMATION
Your child's healthcare provider is the best source of information for questions and concerns related to your child's medical problem.
This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Patient education: Asthma in children (The Basics)
Patient education: How to use your child's dry powder inhaler (The Basics)
Patient education: How to use your metered dose inhaler (adults) (The Basics)
Patient education: Inhalers (The Basics)
Patient education: Medicines for asthma (The Basics)
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Patient education: Asthma symptoms and diagnosis in children (Beyond the Basics)
Patient education: Asthma treatment in children (Beyond the Basics)
Patient education: How to use a peak flow meter (Beyond the Basics)
Patient education: Trigger avoidance in asthma (Beyond the Basics)
Patient education: Asthma treatment in adolescents and adults (Beyond the Basics)
Patient education: Asthma inhaler techniques in adults (Beyond the Basics)
Patient education: Asthma and pregnancy (Beyond the Basics)
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Acute asthma exacerbations in children: Inpatient management
Acute asthma exacerbations in children: Emergency department management
Acute severe asthma exacerbations in children: Intensive care unit management
An overview of asthma management
Asthma in children younger than 12 years: Treatment of persistent asthma with controller medications
Asthma in children younger than 12 years: Initial evaluation and diagnosis
Delivery of inhaled medication in children
The use of inhaler devices in children
The following organizations also provide reliable health information.
●National Library of Medicine
●National Heart, Lung, and Blood Institute
●American Lung Association
●American Academy of Allergy, Asthma, and Immunology
●American College of Allergy, Asthma, and Immunology
- Leversha AM, Campanella SG, Aickin RP, Asher MI. Costs and effectiveness of spacer versus nebulizer in young children with moderate and severe acute asthma. J Pediatr 2000; 136:497.
- Cates CJ, Crilly JA, Rowe BH. Holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute asthma. Cochrane Database Syst Rev 2006; :CD000052.
- Wildhaber JH, Janssens HM, Piérart F, et al. High-percentage lung delivery in children from detergent-treated spacers. Pediatr Pulmonol 2000; 29:389.
- Amirav I, Newhouse MT. Aerosol therapy with valved holding chambers in young children: importance of the facemask seal. Pediatrics 2001; 108:389.
- Marguet C, Couderc L, Le Roux P, et al. Inhalation treatment: errors in application and difficulties in acceptance of the devices are frequent in wheezy infants and young children. Pediatr Allergy Immunol 2001; 12:224.
All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.