Inhaler Devices

Technique and training

Prescribe inhalers only after patients have received training in the use of the device and have demonstrated satisfactory technique. (no evidence for children)

Beta2 agonist delivery

ACUTE ASTHMA

Children aged >=2 with mild and moderate exacerbations of asthma should be treated by pMDI + spacer with doses titrated according to clinical response.

There are no data to make recommendations in children under two or in severe (life-threatening) asthma.

STABLE ASTHMA

For children aged 0-5, there is no evidence comparing nebuliser and other inhalers and the data are insufficiently extensive or robust to draw conclusions for pMDI vs. DPI.

In children aged 5-12, pMDI + spacer is as effective as any other hand held inhaler.

There are no data to make recommendations in children under five.

Choice of reliever inhaler for stable asthma should be based on patient preference and assessment of correct use. Many patients will not be prepared to carry a spacer.

Inhaled steroids for stable asthma

There are no comparative data on inhaled steroids for stable asthma in children under 5 years. A single study included 4-5 year olds, but the data were not extractable.

In children aged 5-12 years, pMDI + spacer is as effective as any DPI.

No recommendation can be given for nebulised therapy in children aged 5-12 years and there is no evidence relating to children aged <5 years.

CFC propellant pMDI vs HFA propellant pMDI

HFA pMDI salbutamol is as effective as CFC pMDI salbutamol at standard therapeutic doses (no evidence for children)

HFA-BDP pMDI (Qvar) may be substituted for CFC-BDP pMDI at 1:2 dosing but should incorporate a period of close monitoring to ensure adequate control. This ratio may not apply to reformulated HFA-BDP pMDIs.

Salbutamol can be substituted at 1:1 dosing. Fluticasone can be substituted at 1:1 dosing when used at a dose of 200 mcg per day. (no evidence for children)

Prescribing devices

There is no evidence to dictate an order in which devices should be tested for those patients who cannot use pMDI. In the absence of evidence, the most important points to consider are patient preference and local cost.

• The choice of device may be determined by the choice of drug.
• If the patient is unable to use a device satisfactorily an alternative should be found.
• The patient should have their ability to use an inhaler device assessed by a competent health care professional.
• The medication needs to be titrated against clinical response to ensure optimum efficacy.
• Reassess inhaler technique as part of structured clinical review (see section

In children aged 0-5 years, pMDI and spacer are the preferred method of delivery of beta2 agonists or inhaled steroids. A face mask is required until the child can breathe reproducibly using the spacer mouthpiece. Where this is ineffective a nebuliser may be required.

Use and care of spacers

• The spacer should be compatible with the pMDI being used.
• The drug should be administered by repeated single actuations of the metered dose inhaler into the spacer, each followed by inhalation.
• There should be minimal delay between pMDI actuation and inhalation.
• Tidal breathing is as effective as single breaths.
• Spacers should be cleaned monthly rather than weekly as per manufacturer's recommendations or performance is adversely affected. They should be washed in detergent and allowed to dry in air. The mouthpiece should be wiped clean of detergent before use.
• Drug delivery may vary significantly due to static charge. Metal and other antistatic spacers have been shown to be effective in this respect.
• Spacers should be replaced at least every 12 months but some may need changing at six months.