Step-by-step guides for common asthma medication delivery devices.
1. Make sure the size of the mask of the spacer is the appropriate one for the size of the child.
2. The mask should just barely fit over the top of the nose, and the bottom lip of the mouth. If 2 sizes are available (eg, Aerochamber Plus Flow-VU), the smallest mask is meant for children aged 1 year or so and younger, and the next size up for children aged older than 1 year, up to around age 5 years.
3. Put the mouthpiece end of the pressurized metered dose inhaler ([pMDI]; canister and holder) in the receiving end of the tube spacer.
4. Shake the pMDI spacer unit vigorously to shake up the medication inside the canister.
5. Put the mask end of the spacer on the face of the child so that there is a tight seal around the nose and mouth.
6. Application of the spacer against the face of the child should occur before actuation of the aerosol.
7. Actuate the aerosol medication into the spacer.
8. Continue holding the spacer and mask tightly against the child's face.
9. Allow the child to do quiet tidal volume breathing. If the child can do some deep breathing, this is even better. Crying is not an effective way to deliver medication to the lungs.
10. Leave the spacer against the face, and allow breathing to occur, for about 10 seconds (4 to 6 breaths).
11. Some valved tube spacers allow for one to see if the child has a good tight seal on the face and is breathing in the contents of the spacer by noting an expiratory valve (some also have an inspiratory valve) move in and out.
12. The next dose of medication is administered by repeating the whole procedure.
1. Remove cap from the MDI. Shake canister 3 or 4 times vigorously.
2. If it needs to be primed (eg, a new canister, or one that has not been used for more than 10 to 14 days), the MDI should be fired or discharged into the air, with the number of puffs being discharged depending on the specific inhaler instructions for that MDI (usually 1 or 2 times).
3. Attach spacer to the MDI. (In the case of a bag spacer, take out the MDI canister and place into the plastic actuator part of the spacer. Note this may not be possible with an MDI that has a counter on the canister.)
4. Shake canister and spacer as 1 unit, vigorously.
5. Exhale normally.
6. The shoulders should be down, and the head/chin in the neutral position.
7. Place spacer mouthpiece into the mouth, and close lips tightly around the spacer mouthpiece. Make sure the mouthpiece is through the teeth, and the tongue is underneath the mouthpiece opening.
1. Discharge 1 puff from the MDI into the spacer.
2. Immediately after discharge (within 1 to 2 seconds or sooner) start to inhale slowly and deeply over 3 to 5 seconds.
3. The chest should expand fully, and the shoulders should go up. The head/chin should stay in the neutral position.
4. Hold breath for 5 to 10 seconds.
1. Wait 10 to 15 seconds before inhaling the next puff (if prescribed). Repeat sequence as above.
2. If the inhaled drug is a corticosteroid, rinse the mouth with water when finished. Spit the water out.
1. Always shake the inhaler vigorously before using.
2. If the inhaler is new, "prime" the inhaler by actuating it 2 or 3 times.
3. There are 2 mouth-positioning techniques that can be used-open- or closed-mouth.
• For open-mouth technique, the child should open his or her mouth fully, and place the inhaler about 2 to 3 fingerbreadths (1 to 2 in) in front of the open mouth. Make sure the inhaler is aimed directly at the center of the opening of the mouth.
• For closed-mouth technique, the child should place the inhaler in his or her mouth, through the teeth, with lips tightly around the mouthpiece of the inhaler, and tongue out of the way of the inhaler mouthpiece opening.
4. The child should relax, and drop the shoulders. The head/chin should be in the neutral position, with chin neither up nor down. The thumb should hold onto the bottom of the inhaler, and the index finger onto the top of the canister, to allow for easy actuation of the inhaler by the 2 fingers pinching down on the canister, making it depress and fire.
5. Just as the child starts to breathe in slowly through the mouth, the canister should be depressed 1 time. There should be minimal delay in starting inhalation after firing the canister.
6. The child should keep breathing in slowly, and as deeply as possible. The deep breath should result in the chest fully expanding, and the shoulders going up. The head should stay close to the neutral position.
7. The child should hold the deep breath for at least 5 seconds, preferably 10 seconds, and then relax.
8. If mist is seen coming out of the mouth after the maneuver is done, the inhalation technique was not likely correct. Also, with closed-mouth technique, if mist is seen coming out of the top of the inhaler right after actuation, the technique was not correct (breathing in was too late after actuation, or the tongue or teeth were in the way of mist).
9. Repeat the above if more than 1 inhalation is prescribed, which is often the case.
1. Open the DPI device and reveal the mouthpiece.
2. Load powder (ie, slide lever, twist and click base, twist cap off, or insert capsule).
3. Avoid tilting the mouthpiece of the DPI down to avoid the powder falling out of the device.
4. Have child put mouth tightly around mouthpiece; hold device horizontal.
5. The child should relax and drop the shoulders. The head/chin should be in the neutral position (chin neither up nor down).
6. Have the child inhale as forcefully and rapidly as possible.
7. Hold breath for just a short time (1 or 2 seconds). A longer breath hold can be done, but is not usually needed with a DPI.
8. Take notice of the counter to determine if it is time to replace the unit.
9. Close the device (slide it closed, or replace the cover cap).
Used with permission from Chitra Dinakar, MD, FAAP, University of Missouri-Kansas City, and Children’s Mercy Hospitals and Clinics, Kansas City; and Michael J. Welch, MD, FAAP, FAAAAI, clinical professor, University of California, San Diego, School of Medicine, and co-director, Allergy and Asthma Medical Group and Research Center, San Diego. Dr Dinakar has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article. Dr Welch reports speaker fees and contracted research for Teva Pharmaceuticals.