Patient information: Asthma inhaler techniques in children

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 artcile discusses the use of asthma inhalers in children. Other topics about asthma in children are available separately. (See "Patient information: Asthma symptoms and diagnosis in children" and "Patient information: Asthma treatment in children" and "Patient information: How to use a peak flow meter" and "Patient information: Trigger avoidance in asthma".)

Articles are also available for adults with asthma. (See "Patient information: Asthma treatment in adolescents and adults" and "Patient information: How to use a peak flow meter" and "Patient information: Asthma inhaler techniques in adults" and "Patient information: Pregnancy and asthma".)

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 (figure 1).

The inhaler canister contains the medicine and other chemicals that helps 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 to the previous inhalers, and the spray may feel softer. However, this does not mean 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 a metered dose inhaler 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 3 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 2 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.

Instructions for using the inhaler are available in table 1 (table 1).

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 cannister 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 an 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 (figure 2 and picture 1).

A spacer is recommended for any child who has difficulty squeezing the cannister 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 a metered dose inhaler.

• 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 cannister.
• If you have difficulty timing your breath while spraying the medication, there are inhalers that automatically release the medication when you take a breath (ie, 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 (picture 1). Nebulizers may be preferred to metered dose inhalers for some children who are too ill or too young to use a hand-held device, and in situations where large drug doses are necessary.

However, recent studies suggest that even infants can use an inhaler properly [1]. 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 [2] (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 (ie, 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 is a dry powder inhaler (DPI). DPIs eliminate the need to coordinate taking a breath and squeezing the cannister. DPIs deliver a fine powder to the lungs when the child breathes in (figure 3). Children who use dry powdered inhalers 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 quick relief/long acting medication Foradil®, the controller medications Asmanex® and Pulmicort® flexhaler, and the combination inhalers Advair® and Symbicort®. 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 (Foradil® Aerolizer, Spiriva® Handihaler), 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 dry powder inhaler are included in table 2A-2B (table 2A-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 their 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 Proventil® (figure 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. Because no two children are exactly alike and recommendations can vary from one child to another, it is important to seek guidance from a provider who is familiar with your child's situation.

This discussion will be updated as needed every four months on our Web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

Some of the most pertinent include:

Patient Level Information:
Patient information: A guide to asthma
Patient information: Asthma symptoms and diagnosis in children
Patient information: Asthma treatment in children
Patient information: How to use a peak flow meter
Patient information: Trigger avoidance in asthma
Patient information: Asthma treatment in adolescents and adults
Patient information: Asthma inhaler techniques in adults
Patient information: Pregnancy and asthma

Professional Level Information:
Acute asthma exacerbations in children: Inpatient management
Acute asthma exacerbations in children: Outpatient management
Acute severe asthma exacerbation in children: Intensive care unit management
An overview of asthma management
Chronic asthma in children younger than 12 years: Controller medications
Chronic asthma in children younger than 12 years: Evaluation and diagnosis
Delivery of inhaled medication in children
Use of metered dose and dry powder inhalers in children
Patient information: A guide to asthma

A number of Web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.

• National Library of Medicine

      (www.nlm.nih.gov/medlineplus/healthtopics.html)

• National Heart, Lung, and Blood Institute

      (www.nhlbi.nih.gov/)

• National Lung Health Education Program

      (www.nlhep.org)

• American Lung Association

      (www.lungusa.org)

• American Academy of Allergy, Asthma, and Immunology

      (www.aaaai.org/patients.stm)

• American College of Allergy, Asthma, and Immunology

      (www.acaai.org/public/)

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