Correct Use of Inhalers in Children With Asthma

Asthma is a common condition in pediatric population, affecting millions of children worldwide. It’s a long term condition which inflames and narrows the airways in the lungs. Asthma causes periods of wheezing, shortness of breath, chest tightness and coughing. People with asthma may experience symptoms that range from mild to severe and that may happen rarely or almost every day. When symptoms get worse, it turns into a condition called ‘asthma attack’.

The main purpose of treatment in patients with asthma is to obtain full control of their symptoms and prevent disease exacerbations, by delivering an optimal inhaled drug dose to the target site of action in the lungs, with minimal or no adverse effects. The preferred method of medication delivery in asthma is through inhalers, which delivers medication straight to the lungs.

An inhaler is a device that is used to deliver aerosolized medication to the respiratory tract directly with minimum side effects. An inhaler is made up of a metal canister inserted into a plastic holder that contains asthma medicine. When the canister is pushed down, a puff of medicine sprays out.

Types of Inhalers

Metered Dose Inhalers

It is a handheld device that delivers a specific amount of medication in the form of an aerosol. It consists of a pressurized canister inside a plastic case, with a mouthpiece attached to it. The device helps in delivering asthma medication directly to the lungs.

Dry powder inhalers (DPIs)

Dry powder inhalers (DPIs) are used to transfer drug into the body. The delivery of a drug into the lungs depends on drug delivery system performance and powder formulation. Dry powder inhalers need to fulfill safety, efficacy, reliability, and bio-equivalence for product approval.

Factors affecting the performance of a drug are:

• Configuration of the mouthpiece
• Length of the mouth piece
• Impaction angle of the powder with devices
• Air inlet size

DPIs are alternatives to metered-dose inhaler (MDI). The drug may be held either in the capsule for manual loading or installed in the device and is ready to use.

Nebulizer

A nebulizer is a device that is used to turn medication into a fine mist that is inhaled through a mouthpiece or mask worn over the nose and mouth. A nebulizer is generally used by people who are not able to use an inhaler, such as infants, young children and those people who are critically ill and need large doses of medication.

Accurate Use of Inhalers

Compared to oral medication, many patients find the inhaled route a little unnatural. This problem is compounded by the fact that the many inhalation devices are difficult to use even by the most compliant patient. The inability to use inhaler devices correctly is a major source of compliance in patients with asthma.

Necessary steps to be taken before using inhalers

• Shake well before use
• Remove the cap from the inhaler and the chamber
• Insert the inhaler into the open end of the chamber
• Place the mouthpiece between teeth and lips and seal around it tightly.
• Breathe out completely
• Press the canister once
• Breathe in slowly and completely through mouth
• Hold breath for 10 seconds to allow the medication to reach the airways of the lung
• Repeat the above steps for each puff
• Wait about 1 minute in between each puff
• After using a corticosteroid rinse your mouth and gargle using water or mouthwash after each use.

Advantages of Metered-dose inhalers (MDI)

• Metered-dose inhalers (MDI) are Easy to carry
• Highly effective and extremely safe
• Allow accurate, consistent dose delivery
• The inhaled route is mostly preferred for the delivery of bronchodilators and corticosteroids which are used in the maintenance therapy of Asthma.
• Small doses of drugs are delivered directly to their site of action
• Rapid onset of action and a low incidence of side effects

Inhaler with spacer

Poor inhaler technique fails to deliver medications deep into the airways where they are needed. The use of an inhaler without a spacer is the most common mistake children usually make.

Spacers are the devices which are used to increase the ease of administering aerosolized medication from a metered dose inhaler (MDI). The spacer adds space in the form of a small tube between the canister of medication and the patient’s mouth, allowing the patient to inhale the medication by breathing in slowly and deeply for five to ten breaths.

Complications that may arise using inhaler alone

The most common adverse effects of an inhaler used without a spacer are candidiasis and dysphonia, which result from the local deposition of inhaled corticosteroids in the oropharynx.

The high or pharyngeal deposition of these steroids also results in increased systemic absorption of the medication. This may cause adverse effects, such as a heightened risk for growth suppression and osteoporosis. The increased toxicity seen with direct inhaler use is not limited to inhaled steroids but is seen with other medications as well.

In addition, inhaler use without a spacer may cause patients themselves to have difficulties in adhering to the medication. Other patients may not adhere to the treatment regimen because of the foul taste of inhaled medications. By removing the larger particles, spacers moderate the “flavor” of many inhalers and thus help to improve adherence.

Cleaning of inhaler and spacer

To clean the inhaler:

• Wash your hands
• Take the canister out of the plastic inhaler cover
• Take the cap off of the inhaler
• Hold one end of the plastic inhaler cover under warm water for 30 seconds
• Turn the plastic inhaler cover upside down and run that end under warm water for 30 seconds.
• If needed, use a toothpick to remove hardened medicine from the small hole inside the plastic inhaler cover.
• Shake off any water on the inhaler cover
• Place cleaned parts of inhaler on a paper towel and let air dry

To clean the spacer:

• Dismantle spacer, if necessary
• Wash all the parts in clean warm water
• Allow the parts to air dry
• When completely dry, reassemble if necessary