The use of inhaler devices in children

Author:: Robert H Moore, MD
Section Editors:: Gregory Redding, MD; Robert A Wood, MD
Deputy Editor:: Elizabeth TePas, MD, MS

Literature review current through: Jan 2024.

This topic last updated: Jan 10, 2022.

INTRODUCTION — The pressurized metered dose inhaler (pMDI) has been a mainstay in the treatment of respiratory diseases, especially asthma, since its introduction in 1956. It is the most commonly prescribed delivery system for administering inhaled bronchodilators and antiinflammatory agents worldwide [1,2]. Spacer devices, when used properly, substantially improve the delivery of pMDI-generated aerosols to the distal airways. The pMDI, used alone or in combination with a spacer or valved-holding chamber, is the most convenient and cost-effective way to administer aerosolized medications for most patients.

Dry powder inhalers (DPIs) are a separate group of medication aerosolizing devices widely used in the management of adult and pediatric pulmonary disease. These devices eliminate the need for propellants and are less dependent upon coordination of inhalation and device actuation. Short- and long-acting beta agonists and inhaled glucocorticoids are available for administration via DPIs.

The effectiveness of both delivery systems is dependent upon several factors, including the properties of the agent administered, design, temperature, humidity, and patient technique [3,4]. Device technique should be assessed during every encounter to ensure optimal use and drug delivery to the lungs. The use of pMDIs and DPIs in children is discussed here. Other aspects of aerosol therapy, including the use of nebulizers, are presented separately. (See "Delivery of inhaled medication in children" and "Use of medication nebulizers in children".)

PRESSURIZED METERED DOSE INHALERS — A pressurized metered dose inhaler (pMDI) contains drug, which usually is either crystallized or in solution, along with the propellant and a surfactant (picture 1) [2].

Propellants — The most common type of propellants used are the hydrofluoroalkanes (HFA). In some cases (such as with HFA beclomethasone), the use of HFA has increased the output of respirable particles [5,6], improved the delivery of drug to the lower airways, and decreased deposition in the oropharynx compared with previously used propellants [7]. Improved delivery to peripheral airways may necessitate the reduction of drug dose, particularly when using an inhaled glucocorticoid [8]. (See 'Spacer devices' below.)

pMDI technique — Advantages of aerosol delivery using a pMDI include convenient multidosing, portability, low cost, and a low risk of bacterial contamination. However, correct coordination of actuation and inspiration is crucial and may be difficult for young children, patients with severe muscle weakness, or patients with hand deformities. Improper technique can increase oropharyngeal drug deposition and side effects.

The effective delivery of drugs by pMDIs is technique dependent. Unfortunately, up to two-thirds of patients and health care professionals who administer pMDI treatment do not use proper technique (table 1 and table 2) [2,9-13]. (See "Patient education: Asthma inhaler techniques in children (Beyond the Basics)".)

Priming the pMDI — Priming of all pMDIs is recommended before their initial use to ensure accurate mixing of propellant and medication in the metering chamber (table 3). Priming involves the discharging of one or more doses of medication prior to use. pMDIs have extra doses to account for the initial priming [14]. Additional priming may be recommended by the manufacturer if a period of time has elapsed between uses or if the pMDI is dropped.

Determining when an MDI is empty — It is important for the patient to have a means to determine when the canister is empty. It is not possible to determine when an MDI canister is empty by shaking it, because some propellant remains in the canister after all of the medication has been used. Many MDIs are now manufactured with integrated dose counters (picture 2) [15]. Another method of determining when the canister is empty is to have the patient maintain a log of the number of actuations and to dispose of the device when the designated number of actuations has been reached or upon expiration, whichever is sooner. The technique of dropping the canister into a pan of water and observing how it floats is unreliable and is no longer recommended [16,17].

Spacers and holding chambers — Most problems associated with pMDI use, such as the need for coordination of actuation and inhalation, are related to the high velocity of discharge of particles from the nozzle [4,18,19]. The attachment of a spacer to the pMDI decreases the velocity of particles and largely eliminates the need for coordination [2,18,19]. A spacer is usually an open-ended tube or bag that is of sufficient volume to allow the aerosol plume from the pMDI to expand, the propellant to evaporate, and large particles to settle (picture 3) [2].

There is no evidence that adding a spacer improves drug delivery or efficacy as compared with a correctly used pMDI alone [20,21], but the addition of a spacer does correct for poor pMDI technique in most patients and allows faster resolution of symptoms in children with acute asthma [2,19,22-25]. In addition, using a spacer markedly decreases oropharyngeal drug deposition and may reduce both oral and systemic side effects, especially when used with inhaled glucocorticoids [19,26,27].

The use of a spacer or valved-holding chamber is recommended for all children in whom proper breath and actuation coordination is difficult (particularly those who are younger than five to six years) and whenever an inhaled glucocorticoid is being administered via a pMDI. A valved-holding chamber with a mask is recommended for younger children, especially those under three years of age. Most children can be successfully changed to a chamber with mouthpiece as they get older. (See "Major side effects of inhaled glucocorticoids" and "Asthma in children younger than 12 years: Management of persistent asthma with controller therapies".)

Spacer devices — The spacer should be at least 100 to 700 mL in volume and should provide a distance of 10 to 13 cm between the pMDI nozzle and the mouth [2]. In a randomized crossover study of spacers with facemasks in children aged 10 to 25 months, a smaller-volume 140 mL Aerochamber was less effective than the larger-volume 260 mL Babyspacer and 750 mL Nebuhaler (filter dose of budesonide 39.4, 53.5, and 55.5 mcg, respectively) [28]. However, using a large-volume spacer device may require longer administration times (up to 30 seconds) to empty the spacer. In another study of spacers without facemasks, children two to seven years of age had inhalation volumes nearly double the expected tidal volumes [29]. Two tidal breaths were sufficient for the smaller-volume spacers (149 mL Aerochamber Plus and 225 mL Funhaler) and a 500 mL modified plastic soft drink bottle, but three tidal breaths were required for the larger-volume spacer (750 mL Volumatic). Additional tidal breaths did not significantly increase drug delivery. For infants and younger children, we recommend five to six tidal breaths to ensure complete emptying of the chamber. Drug delivery was otherwise equivalent among the four devices. The modified 500 to 1000 mL plastic bottle is an approach that may be particularly useful in resource-limited countries [30-33].

A number of spacer devices are commercially available. Examples include InspirEase, Aerochamber, Nebuhaler, ACE, VORTEX, and OptiHaler, among others (picture 3). The various spacers differ mainly with regard to size, shape, presence of a valve, and use of an inspiratory flow alarm (signaling too rapid inspiration).

Plastic spacers have electrostatic charges within the chamber that attract particles and significantly reduce drug delivery to the lungs [5,34-37]. This effect may be particularly important when starting bronchodilator therapy in acute asthma. One option is to use a nonelectrostatic metal spacer where available [38,39]. Alternatively, the electrostatic charge within the plastic spacer can be reduced by washing the spacer in a dilute solution (1:5000 or three to four drops in a gallon of water) of dishwashing detergent, without subsequent rinsing, prior to its use [36,40-42]. The spacer also can be primed with several doses (10 to 20) of drug with the initial use [5,36,43], but this method generally is impractical given drug costs and limitations on refills, particularly with controller medications. These treatments improve drug delivery by as much as fourfold [40,43].

Valved-holding chambers — The valved-holding chamber is a specialized spacer that incorporates a one-way valve that permits aerosol removal from the chamber during inhalation and holds particles in the chamber during exhalation [44]. These devices can be fitted with a mouthpiece or a size-appropriate facemask, making them suitable for use in infants and young children. When using a facemask, it is important that it is well sealed and that dead space volume is minimized to assure optimal drug delivery [45-49]. Flexible masks appear to provide better seals and are associated with smaller dead space volume than rigid masks [47,48]. There is some evidence that a valved spacer may not be appropriate when using a pMDI in newborns and very small infants, due to their inability to reliably generate the inspiratory flow necessary to open the valves [50]. (See "Delivery of inhaled medication in children".)

Spacer technique — As with other aerosol delivery devices, proper instruction in administering drugs via pMDIs with spacers is critical to achieve optimal effect. In one study, almost half of parents received inadequate instruction in spacer use for infants and young children [51]. Although most of the parents thought that the procedure was easy to understand, errors that affected the efficiency of medication administration were common [51]. The optimal technique for using a pMDI with spacer or valved-holding chamber is reviewed in the tables (table 1 and table 2) [2,37,52]. Factors that affect drug deposition of inhaled medications in infants and children are discussed in detail separately. (See "Delivery of inhaled medication in children".)

Cleaning the spacer — Periodic cleaning of the spacer is recommended, even though the powder residue that is deposited in the chamber is not harmful. When a plastic spacer is cleaned with water, an electrostatic charge that attracts aerosol particles is present during the first 10 to 20 actuations, reducing drug deposition in the lungs [2]. Washing the spacer in a dilute solution of dishwashing detergent, without subsequent rinsing, decreases static charge and improves drug delivery [5,36,40,41]. (See 'Spacer devices' above.)

pMDI or nebulizer? — Many clinical trials and meta-analyses indicate that the administration of beta agonists via pMDI with spacer is at least as effective as, and possibly superior to, delivery of medication by jet nebulizer in reversing acute bronchospasm in infants and children [53-60]. In addition, patients using a pMDI with spacer may experience fewer side effects (vomiting, tremors, hypoxemia, tachycardia) as compared with those using a jet nebulizer [53,58,61,62]. The advantages and disadvantages of pMDI and valved-holding chamber over nebulization are reviewed in the table (table 4) [63,64]. (See "Use of medication nebulizers in children".)

pMDIs were equal or superior to nebulizers in studies of small infants with bronchopulmonary dysplasia [65], wheezy infants between 4 and 12 months of age [56], and young children with moderate-to-severe asthma [66], indicating the appropriateness of bronchodilator therapy via a pMDI and valved-holding chamber in all age groups. In young children with moderate-to-severe acute asthma, the pMDI with valved-holding chamber produced a greater reduction in wheezing and significantly decreased the need for admission (33 versus 60 percent) as compared with the jet nebulizer [66].

Data suggest that four to six puffs of albuterol by pMDI and valved-holding chamber are therapeutically equivalent to 2.5 mg by jet nebulizer [67,68]. In addition, the dose of drug delivered via pMDI with valved-holding chamber can be readily titrated to clinical effect, which may decrease side effects and reduce cost [66,68]. These data have led some authors to suggest that the pMDI with valved-holding chamber should be the preferred method for administering bronchodilators to infants and children with acute asthma at home, as well as in the emergency department and hospital [68,69]. (See "Acute asthma exacerbations in children younger than 12 years: Emergency department management" and "Acute asthma exacerbations in children younger than 12 years: Inpatient management".)

DRY POWDER INHALERS — A dry powder inhaler (DPI) is a breath-actuated device containing micronized drug particles with a mass median aerodynamic diameter (MMAD) of less than 5 micrometers that are usually aggregated with carrier particles (such as lactose or glucose) of greater diameter [2,70]. Drug is delivered to the airways by the inhalation of air over a punctured drug-containing capsule or blister. Proper technique for various DPIs is reviewed in the table (table 5).

DPIs have several advantages compared with pressurized metered dose inhalers (pMDIs), which are reviewed in the table (table 4). DPI devices eliminate the requirement for propellants as well as for coordination between inhalation and device actuation. Drug administration is faster with DPIs than nebulization [71]. The clinical effects of drugs administered by DPI are similar to those administered by pMDI. This is true even when beta agonists are administered in the treatment of acute asthma [72,73]. There is evidence that at least some of these breath-actuated, dry powder devices (eg, Turbuhaler) actually enhance pulmonary deposition of inhaled glucocorticoids and provide equal improvement in lung function at a lower dose compared with MDIs [74]. In addition, oropharyngeal side effects appear to be less common when glucocorticoids are delivered by DPI [75].

Disadvantages of DPIs are reviewed in the table (table 4). Relatively high inspiratory flow rates (30 to 120 L/min) are required to deaggregate and aerosolize the drug [2,70,76]. In one study, the age at which most children who were inexperienced in the use of a DPI could generate a peak inspiratory flow rate of ≥30 L/min was four years, and the age at which most children could generate a peak inspiratory flow rate of ≥60 L/min was nine years [76]. The requirement for an inspiratory flow rate of at least 28 L/min makes these devices less useful in young children. In addition, the rapid inhalation that is required to insure optimal lung deposition, a technique different from that required for pMDIs, may be confusing for children who use both types of devices.

Device selection — Short- and long-acting beta agonists and inhaled glucocorticoids are available for administration via DPIs. In addition, a dry powder formulation of tobramycin is available for patients six years of age and older who have cystic fibrosis and are colonized with Pseudomonas aeruginosa [71]. A number of different types of DPIs are commercially available (table 5 and picture 4).

There is a simple way to assess the ability of a child to use a DPI using a paper tissue [77]. A tissue is held in both hands and placed over the open mouth. The patient then inhales forcefully, creating a vacuum that keeps the tissue in place after letting go of the tissue. The goal is to keep the tissue in place on the mouth for five seconds while breathing in without holding the tissue.

Assessing adequacy of inspiratory pressure — Several factors may influence the efficiency of drug delivery by DPIs. The age of the child and presence of asthma symptoms affect peak inspiratory flow [76,78]. In addition, the design of the device affects the resistance to inspiration and the inspiratory flow required to aerosolize the medication. For instance, the Diskus is reliable at both low and high flow rates [76,79] and may be suitable for use in children as young as four years of age and patients with severely impaired lung function (forced expiratory volume in one second [FEV₁] less than 30 percent predicted) [80]. In contrast, high-resistance devices, such as the Turbuhaler, require greater inspiratory flow to efficiently aerosolize a high percentage of the nominal dose and are not as reliable at lower inspiratory flow rates or in patients with severe airway obstruction [80]. However, the Turbuhaler may provide better drug deposition to the lower airways if flow rate is adequate [3,81]. The ProAir (albuterol) Digihaler has a built-in sensor that records objective data, including a timestamp of inhaler use and inspiratory flow rate generated [82]. Wireless technology sends the information to the companion mobile app, which also reminds patients to check their dose counter.

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they 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. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: How to use your child's dry powder inhaler (The Basics)" and "Patient education: How to use your child's metered dose inhaler (The Basics)")

●Beyond the Basics topics (see "Patient education: Asthma inhaler techniques in children (Beyond the Basics)" and "Patient education: Asthma symptoms and diagnosis in children (Beyond the Basics)")

SUMMARY

●The two main types of inhaler devices used to administer aerosolized medications are the pressurized metered dose inhaler (pMDI) and the dry powder inhaler (DPI). The effectiveness of both delivery systems is dependent upon several factors, including the properties of the agent administered, design, temperature, humidity, and patient technique. Device technique should be assessed during every encounter to ensure optimal use and drug delivery to the lungs. (See 'Introduction' above and "Delivery of inhaled medication in children".)

●A pMDI contains drug, which is usually either crystallized or in solution, along with the propellant and a surfactant (picture 1). Advantages of aerosol delivery using a pMDI include convenient multidosing, portability, and a low risk of bacterial contamination (table 4). However, correct coordination of actuation and inspiration is crucial (table 1 and table 2) and may be difficult for young children, patients with severe muscle weakness, or patients with hand deformities. Improper technique can increase oropharyngeal drug deposition and side effects. (See 'Pressurized metered dose inhalers' above.)

●Most problems associated with pMDI use, such as the need for coordination of actuation and inhalation, are related to the high velocity of discharge of particles from the nozzle. The attachment of a spacer or valved-holding chamber to the pMDI decreases the velocity of particles and largely eliminates the need for coordination (table 1 and table 2). A spacer is usually an open-ended tube or bag that is of sufficient volume to allow the aerosol plume from the pMDI to expand, the propellant to evaporate, and large particles to settle (picture 3). (See 'Spacers and holding chambers' above.)

●Many clinical trials and meta-analyses indicate that the administration of beta agonists via pMDI with spacer is at least as effective as, and possibly superior to, delivery of medication by jet nebulizer in reversing acute bronchospasm in infants and children. In addition, patients using a pMDI with spacer may experience fewer side effects compared with those using a jet nebulizer. (See 'pMDI or nebulizer?' above.)

●A DPI is a breath-actuated device containing micronized drug (table 5 and picture 4). These devices eliminate the need for propellants and are less dependent on coordination of inhalation and device actuation (table 4). However, relatively high inspiratory flow rates are required to deaggregate and aerosolize the drug. (See 'Dry powder inhalers' above.)

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Burnell PK, Small T, Doig S, et al. Ex-vivo product performance of Diskus and Turbuhaler inhalers using inhalation profiles from patients with severe chronic obstructive pulmonary disease. Respir Med 2001; 95:324.
Svartengren K, Lindestad P, Svartengren M, et al. Added external resistance reduces oropharyngeal deposition and increases lung deposition of aerosol particles in asthmatics. Am J Respir Crit Care Med 1995; 152:32.
ProAir (albuterol) Digihaler FDA package insert. https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/205636Orig1s012lbl.pdf.

Topic 5738 Version 15.0

خرید پکیج

The use of inhaler devices in children

References